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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The crowded, congested, contested road: unsafe at nearly every speed

Seattle traffic
Seattle traffic is among the worst in the nation, and it can be downright deadly, according to those who track road-related fatalities.

Every day that I drive to work, I am literally putting my life on the line. I commute roughly 80 miles daily, round trip, from Seattle to Tacoma, navigating one of the most harrowing urban traffic corridors in the Untied States, on Interstate 5 and two state highways. (My story why I am commuting this way will be for another day, but there are good reasons.)

Routinely, erratic drivers dangerously pass me, putting our lives at risk, in order to gain a few extra minutes by speeding. I have seen many accidents, some fatal, on this route over the years, and I am glad that I have my will and living will in proper order in case a truck jack-knifes near me in the rain—and yes I’ve seen that happen twice before on the freeway system around Seattle.

Seattle Road Kill 2001-2009
How deadly are roads in the Puget Sound–take a look at the roadkill on this data map showing types of mortality by form of transportation for 2001-2009.

Judging by this map, we get a fair share of road kill in the metro area I call home.

The Centers for Disease Control and Prevention (CDC) put the number of road deaths annually in my home state at nearly 500 (2009). Nationally, in 2012, the United States reported that 34,080 people died in motor vehicle traffic crashes in 2012, a 5.3% jump over 2011. This ranks as 10th leading cause of death in the United States, if one pulls this form of death from all accidental deaths, in which it is grouped by the CDC epidemiologists.

So by all counts, getting in one’s car (or on one’s bike or in a bus or other form of transportation) and hitting the road can be deadly business in my country, especially given the proliferation of mobile-device users and drunk drivers.

In 2011, cell phone use in the good ole’ U.S.A. was a contributing factor in more than 3,300 deaths and for the previous year, in 387,000 motor vehicle injuries. These are very sobering numbers, and I actually expected there would be more given that I have seen far too many texters during peak travel times in vehicles moving 70 mph. Normally I move over a lane or lay on my horn to snap them out of it.

But this is nothing compared to the perils that passengers and drivers experience globally. According to the World Health Organization (WHO), road accidents claimed 1.2 million lives globally in 2011, ranking as the No. 10 cause of death, on a list that has some pretty nasty company, including respiratory infections (3.5 million), tuberculosis (1.3 million), and the big killer of children ages 0-5 years, diarrhea (2.5 million).

The Institute for Health Metrics produced this data table showing how road deaths globally compared to other causes of death (it's No. 10); go to: http://www.healthmetricsandevaluation.org/gbd/visualizations/gbd-heatmap
The Institute for Health Metrics produced this data table showing how road injury globally compares to other burdens of disease (it is No. 10); go to: http://www.healthmetricsandevaluation.org/gbd/visualizations/gbd-heatmap

A typical story that one sees with mind-numbing frequency overseas are bus collisions with motorcycles and motor scooters. This November 2012 story, 19-yr-olds crushed to death by bus, notes two aspiring young men were run over by an errant bus driver and dragged 40 feet in Chandigarh, India; the driver then fled the scene. Both of the men’s heads were crushed by the bus’s wheels.

I saw no less than three similar road maulings on the island of Java in 2009, when I visited Indonesia. That island, one of the most densely populated locations in the world, is overwhelmed with low-income and middle-income residents on  scooters competing for space with trucks and army of loosely and unregulated van taxis and buses.

Indonesians who use these highly efficient and inexpensive 100-125cc motor scooters are frequently killed on the island nation's infamously unsafe and crowded roads.
Indonesians who use these highly efficient and inexpensive 100-125cc motor scooters are frequently killed on the island nation’s infamously unsafe and crowded roads.

Road accidents alone in Indonesia account for more than 48,000 deaths annually, the 9th leading cause of death in the world’s largest Muslim nation.

The United States Department of State offers this stern warning to would-be American visitors to Indonesia–a country I really loved by the way: “Air, ferry, and road accidents resulting in fatalities, injuries, and significant damage are common. … While all forms of transportation are ostensibly regulated in Indonesia, oversight is spotty, equipment tends to be less well maintained than that operated in the United States, amenities do not typically meet Western standards, and rescue/emergency response is notably lacking.”

During my two-week visit in 2009 to the island nation, I rode about a dozen different buses and equally as many microbuses, not to mention the country’s crash-prone domestic air carriers once, their local train service (also unsafe at times), and the far less safe inter-island ferry services. I saw about a half dozen crashes from my bus window, most fatal and usually with motor cycle riders as victims, and from my hotel room I heard one multi-vehicle crash in the middle of the night that clearly claimed many lives. I learned the next day it was between a bus and truck. The bus was totaled.

Roads can really kill you overseas, and so can planes, boats, and trains too

Buses like these are cheap in Indonesia, but your life can be as some locals would say, insha-Allah, or at the mercy of God.
Buses like these are cheap in Indonesia, but your life can be as some locals would say, insha-Allah, or at the mercy of God.

The writer Carl Hoffman, author of the book The Lunatic Express: Discovering the World… via Its Most Dangerous Buses, Boats, Trains, and Planes, documents the horrendous conditions of ferries, public transportation, trains, planes, and other forms of transport. The book’s online promotion notes that it offers a “harrowing and insightful look at the world as it is, a planet full of hundreds of millions of people, mostly poor, on the move and seeking their fortunes.”

Anyone who has travelled in developing or “middle-income” countries (like, say, Chile or Turkey) knows their life is literally in the hands of drivers who may have no proper training, in busses with no proper maintenance or even reliable brakes. Worse, the drivers of buses and microbuses in countries from Uganda to India to Mexico may trust their fate to Allah, Saint Christopher, the Virgin Mary, or Krishna. Those who have travelled in such places know this to be true, by the many religious deities dangling at the front of public transportation by the drivers’ seats.

Worse, the drivers will often play chicken with their competitors by speeding into oncoming traffic at high speeds while passing other vehicles or simply to “have fun.” I swear I thought I would die on many occasions in: Mexico, Guatemala, Nepal, Peru, Uganda, Indonesia, Egypt, Turkey, Chile, Argentina, India, and other places that I’d rather forget just now.

accident or more by Birn
When is an accident really an accident, or when it is linked to larger systems issues? This analysis is provided by Anne-Emmanuelle Birn in her description of the social determinants of health (SDOH).

Three separate times, after I lived through the near mishap, I swore I would never, ever take a bus again in a developing nation. Yet I threw caution to the wind, as I needed to get around, and I could not afford to get around any other way. Not seeing the country I was visiting was not an option.

Is it really  “just an accident” or something more?

Anne-Emmanuelle Birn, international health professor at the University of Toronto, and co-author of the widely used global health tome called Textbook of International Health, points out the deeper connections that road-related deaths have to poverty and social inequity in undeveloped and middle-income countries. Birn writes that road traffic accidents are the second-leading cause of death for children between 5 and 14 years of age globally, and that poor and working classes are disproportionately affected in most countries. In high- income countries, most of those killed are drivers and passengers, whereas in low- and middle-income countries pedestrians, cyclists, and public transport passengers make up nine out of every 10 road-related deaths.

In Haiti, for instance, the word for local transport is molue (“moving morgue”) and in southern Nigeria locals say danfo (“flying coffins”).

Duncan Green, an Oxfam policy adviser and development blogger, recently wrote an article asking when road traffic injuries would finally be recognized as a priority by the international development community.

In fact a major report released in June 2013 by the Overseas Development Institute, the United Kingdom’s leading development think tank, notes that transportation is not recognized as a human right like access to water, yet it still is a fundamental factor for many to achieve basic human rights. Well-run transportation systems, for people and for goods and services, promote benefits, while unsafe and weak transportation systems harm the most vulnerable citizens.

Given the debate emerging now for future sustainable development post-2015, the deadline set for the Millennium Development Goals, road safety may finally find a way into the broader public health, development, and environment agenda, as a way to tackle this clearly documented major global killer. Perhaps the threat may finally be treated as the international epidemic that is is, globally or closer to home in the United Sates. For me, this includes the roads in the Puget Sound where I spend more than two hours daily to and from my public health job.

The politicization of public health (and everything else too)

maherobama
Click on the photo to open a link to the video clip of Maher’s commentary.

Some might say TV host Bill Maher is so political that he cannot be trusted. I disagree.

On March 8, on his TV show, Maher delivered a very provocative commentary that everyone in the field of health promotion, public health, and public policy should watch. Maher rightly asked, “Since when in America did everything have to be so political?” It was a smart piece of punditry, because he correctly showed how efforts to promote public health, nutrition, and healthy eating had become as politicized as the debate over regulating the proliferation of firearms.

Showing pictures of First Lady Michelle Obama, a champion of a national nutrition and exercise campaign called Let’s Move, Maher opined, “If seeing this nice lady on TV saying she likes the movies, or nutrition, or exercise fills you with rage, get help.”

Maher further correctly noted, “Big portions, conservative; knowing where your food came from, liberal.” In short, Maher said what few in the public health profession are saying or have the courage to say—that a deep schism exists in the public space that taints and will continue to taint all efforts to tackle some of this country’s biggest health problems.

These include the obesity epidemic and the threat posed to our healthcare system and our national health by chronic disease.

Ever a political lightning rod who is ready to fan conservative flames, former half-term Alaska Gov. Sarah Palin used her speaking appearance  at the 40th annual Conservative Political Action Committee (CPAC) conference on March 16, to lambaste New York City Mayor Michael Bloomberg’s efforts to tackle obesity by limiting the size of sugary-sweetened beverages. Bloomberg’s New York City law to limit the serving size of such drinks to just 16 ounces was  overturned by a New York State Judge on March 11.

This perfectly framedAP file photo from March 16 shows Palin's eager embrace of red-meat politics that seeks to prevent small measures to address the proliferation of obesity in the United States.
This perfectly framed AP file photo from March 16 shows half-term former Alaska Gov. Sarah Palin’s eager embrace of red-meat politics that seeks to prevent small measures to address the proliferation of obesity in the United States.

Completely ignoring the obesity crisis that is afflicting her own former state and the country, where two-thirds of all residents are obese or overweight, Palin slurped soda from a 7-11 Big Gulp. The theatrics, all perfectly inline with Palin’s anti-government theology, again proved Maher’s point about the politicization of even micro efforts by some local elected officials to address the public health threats facing the country. (Side note, Palin briefly was governor when I lived in Alaska, and I saw her at health promotion events like community runs–an action that she likely would brand as “liberal” today.)

Whenever I would engage Puget Sound area public health officials during my two years of study at the University of Washington School of Public Health (2010-’12), I always asked, how can you prevent the public perception that efforts to promote healthy activity and nutrition are not perceived by conservative voters and Republican elected officials as part of a liberal, activist agenda. I never got a good answer, mainly because I do not believe those officials had an answer. I did not draw any great wisdom from my faculty or UW SPH peers either.

Some wonkish types have tried to investigate this issue in “philosophical terms,” along traditional axes of egalitarianism/choice minded conservatism against regulation-minded “big government” liberalism. One 2005 article on responsibility in health care choices argued, “Holding individuals accountable for their choices in the context of health care is, however, controversial.” There may be some truth to this, but I discount the “core political values” explanation as a way of understanding the politicization of public health initiatives.

Perhaps the biggest fight  in the U.S. political system today is over tax policy and the future of major social/medical programs—Social Security, Medicare, Medicaid—that provide the true underpinning to the public wellness of our country. This is, at its core, is vicious political battle that will shape the public health of the country unlike any action taken by any regulatory or health agency of the U.S. government.

Regulation to promote health has been at the heart of the public health enterprise ever since the field emerged as a profession in the United States in the late 1800s. According to the Centers for Disease Control and Prevention, many of the most successful public health achievements of the 20th century  (food safety, motor vehicle safety, identifying tobacco as a health hazard, etc.) were “upstream” interventions that, by definition, were regulatory in nature and thus purely political.

However, public health, by being a public enterprise, is by definition a creature of the political process, and thus influenced through the power of the purse to curtail its authority and stymie its reach. Public health departments today, for instance, are managed by publicly accountable officials. A local public health department board of health, like King County’s, includes a broad range of elected officials and a few medical professionals.

The nation’s leading de facto public health official, the U.S. Surgeon General (Dr. Regina Benjamin), today remains a mostly toothless position that has little if no sway over the public policy debate concerning the nation’s public health, according to New York Times health blogger Mark Bittman. He writes, “… there is no official and identifiable spokesperson for the nation’s public health, and the obfuscation and confusion sown by Big Food, along with its outright lies and lobbying might, has created a situation in which no one in power will speak the truth: that our diet is making us sick, causing millions of premature deaths each year and driving health care costs through the roof.”

I personally believe that the position of Surgeon General remains that of a paper tiger because those who have power, members of Congress and the Executive Branch, do no wish to allow an advocate for public health to embarrass them with pesky things like facts and science that call for action.

Dr. C. Everett Koop, former U.S. Surgeon General and effective communicator and advocate for public health.
Dr. C. Everett Koop, former U.S. Surgeon General and effective communicator and advocate for public health.

The most effective Surgeon General in living memory who recently passed away in February, the late Dr. C. Everett Koop, proved unpredictable. Though a staunch conservative appointed by President Ronald Reagan, Dr. Koop staked out very controversial political positions on moral and medical grounds, in defiance of his boss, Reagan.

His notable actions still stand out today for their audacity to challenge powerful interests and their embrace of morality as a tactical advocacy tool:

  • Koop’s office produced the plainly worded, 36-page “Surgeon General’s Report on Acquired Immune Deficiency Syndrome,” which clinically detailed HIV transmission, making clear it was not spread by casual contact and affirming that, “We are fighting a disease, not people.” Koop promoted sex education and condom use, enraging conservative critics.
  • Koop also took on the all-powerful tobacco industry and lawmakers who received its many contributions with his pronouncements that smoking killed and should be banned. He famously called purveyors of cigarettes the “merchants of death.” (When is the last time anyone has heard a medical leader embrace such powerful language for a public health cause?)

Though Koop reportedly claimed morality never “clouded his judgment,” he remained an effective advocate on the bully pulpit by literally shaming those in power. “My whole career had been dedicated to prolonging lives,” he said, “especially the lives of people who were weak and powerless, the disenfranchised who needed an advocate: newborns who needed surgery, handicapped children, unborn children . . .people with AIDS.”

I keep waiting for someone, anyone besides billionaire Mayor Bloomberg, to enter the political discourse on behalf of public health and use straight language that cuts through the hype. The problem is, they cannot teach you leadership when you enter the fields of public health or politics. It is something you either are capable of, or simply lack. Right now, it is lacking.

How research on gun violence is muffled, and who refuses to shut up

On the first day in the new year, I read one of what will become thousands of similar stories that will be published this year in the United States about how firearms were involved in completely senseless and preventable violence.

To understand why we have so many shootings, one may wish to buy this book: Armed America: Portraits of Gun Owners in Their Homes by Kyle Cassidy. Go to http://www.armedamerica.org/. The cover photo provides a shockingly good insight into the national crisis over gun related violence.
To understand why the United States has so many shootings, one may wish to buy this book, Armed America: Portraits of Gun Owners in Their Homes, by Kyle Cassidy. Go to http://www.armedamerica.org/. This book cover photo offers one perspective on the national crisis over the nation’s gun-related violence.

In this particular instance, a 54-year-old woman reportedly shot a  24-year-old man in the thigh over a dispute that he was shooting fireworks at her property in rural Lake Stevens, Wash. No, I am not making this up.

While no one died in this New Year’s eve confrontation, the story barely received three paragraphs of news coverage, as it lacked the dramatic horror that the media exploit when mass homicides occur involving often-legally purchased weapons. There were no dead children or mentally deranged men in military gear loaded with weaponry. Were this story to occur in Canada, or say Japan, it would have received much different coverage.

While we may assume this seemingly “bland” shooting will be counted in national data, that is not guaranteed. It likely could be ignored.

In response to uncertainty over national data, Slate Magazine, on Jan. 1, 2013,  published a story called How Many People Have Been Killed by Guns Since Newtown?. The article alleges guns statistics are “surprisingly hard to come by.” Slate claims it will track the toll of gun related killings with an an anonymous publisher with the Twitter feed @GunsDeath to create an interactive tracking feature. The articles asks readers  who know about gun deaths in their community that are not counted on its interactive map  to tweet @GunDeaths with a citation, and it will be added to the feed.

brady center stat count
The Brady Center keeps a daily tab on gun violence–go to the right corner of the center’s home page for the shooting count, based on CDC data.

The Brady Center, the best known nonprofit that is working to pass legislative fixes to issues such as the sale of semi-automatic weapons and closing loopholes that allow for guns sales without background checks, uses data from the Centers for Disease Control (CDC) (2008-09 estimates). It then makes an estimate of the number of killings a day that may not correspond to the most recent trends. The source data is captured by the CDC National Center for Injury Prevention and Control, reported and accessible through the web-based Injury Statistics Query and Reporting System.

A lesson in how to silence public health researchers, and yes it is about the money

Slate’s professed shock at the lack of poor tracking of gun-related fatalities should actually surprise no one who has monitored the muzzling of research on gun-related violence since the 1990s by the National Rifle Association (NRA), the gun industry’s lobby, and its allies in Congress.

According to a newly published article by Dr. Arthur L. Kellermann and Dr. Frederick P. Rivara (both of whom have MPH degrees), in the Dec. 21, 2012, edition of the Journal of the American Medical Association, gun research at research universities that is funded by the federal government has been systematically quieted by pro-gun forces since a ban was enacted on the CDC in 1996, mainly through budget language. Pulling funding, in effect, silenced the nation’s public health agency on a critical public health issue.

The budget language, which remains in effect today, stated “none of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control.” While it is not clear why individual CDC officials or even highly paid medical and public health professionals have not more publicly risked their professional standing to challenge this language, the authors of the study note, “Extramural support for firearm injury prevention research quickly dried up. Even today, 17 years after this legislative action, the CDC’s website lacks specific links to information about preventing firearm-related violence.”

Rivara and Kellermann further state that the language restricting such research was expanded after a 2009 study that was federally funded, this time by the National Institute on Alcohol Abuse and Alcoholism, if a gun increases or reduces the risk of firearm assault. Congress, in 2011, during the Obama administration and amid the Tea Party insurgency of 2010, “extended the restrictive language it had previously applied to the CDC to all Department of Health and Human Services agencies, including the National Institutes of Health.”

The two authors highlight other efforts taking place national to stifle medical professionals from speaking out, such as Florida’s law (HB 155), which put health care practitioners at risk of penalties, including the loss of their licenses, “‘if they discuss or record information about firearm safety that a medical board later determines was not ‘relevant’ or was ‘unnecessarily harassing.'”

How silencing plays out at research universities, quietly and likely without intent

This blog has reported that the silence within the research community can be found at major public health research programs, such as the University of Washington School of Public Health, which  I attended from 2010 to 2012. I was unable to find any faculty actively teaching future public health leaders–my classmates–about firearms safety research or gun violence in the school’s public health curricula.

It should be noted Dr. Rivara is an adjunct faculty member of the UW School of Public Health, and Dr. Kellermann and he are also graduates of the same school (for their MPH degrees). Dr. Kellerman was in fact my graduation commencement speaker, and proved to be a passionate scientist and advocate to all of us. However, my review of courses did not reveal any classes focussing on gun violence as a public health issue; this does not mean Dr. Rivara and other faculty did not cover this topic in their classes. (It should also be noted that a keyword search for “guns” on the UW SPH web site today, Jan. 2, 2013, yielded only three pages, one focussing on Dr. Rivara and another focussing on Dr. Kellerman.)

During my studies there, I repeatedly raised this anomaly to my professors and during seminars in front of as many faculty as possible–often to the point of becoming an annoyance to those who had heard me ask the same questions repeatedly. But short of actually sitting in on faculty strategy sessions or having any survey data, it is impossible for me to know the reasons why my former school choose not to include this topic in its curricula. There were and remain classes on issues that do receive federal funding: tobacco cessation, obesity and nutrition, maternal and child health, and much more. All are worthy topics, but these were the winners, guns was a loser.

My guess remains it was purely a matter of funding, or lack of funding, and the intense internal pressure on junior faculty to pursue research dollars highly coveted by all departments that were not tied to this pariah topic. Thus the silencing of research continued, without any alarm bells raised from a larger community of researchers, who should be the most active and who should have been leaders, locally and nationally. That is how it works.

Dr. Rivara’s primary role is as a faculty member at the UW School of Medicine, Department of Pediatrics. To his credit, he has shown continued national leadership on gun violence. He and Dr. Kellerman deserve great praise for their lifelong service and work on this topic. Hopefully their article also will shame and embarrass their distinguished academic peers–locally and nationally–into either creating endowed teaching positions or a campaign drive to fund research that can shed light on this national public health crisis that has seized the nation’s attention since the massacre of 20 children and six faculty in a public school in Newtown, Conn. in December. MPH students also can lobby for change too, despite the hazards of confronting faculty who grade and often employ them as assistants.

Given that many faculty at these institutions can earn salaries well above $200,000 annually, some may be reluctant to jeopardize their professional careers or positions in the name of public-minded research on a topic that is at the center of one of the nation’s greatest moral debates since the Civil Rights movement and perhaps since the violent ending of slavery during the Civil War.

Gun researchers who have not been silenced by budget threats

Researchers not blocked by the ban on the CDC and NIH have shown that a prized policy goal of the NRA and gun makers, expanding “standing your ground laws,” have lead to more homicides.Researchers have found that states with a stand your ground law record more homicides than states without such laws.

Data from the study by Hoestra and Cheng, as published on the NPR.org web site (Jan. 2, 2013).
Data from the study by Hoekstra and Cheng, as published on the NPR.org web site (Jan. 2, 2013).

Two economics researchers at Texas A&M University, Mark Hoekstra and Cheng Cheng, found that the laws “do not deter burglary, robbery, or aggravated assault. In contrast, they lead to a statistically significant 8 percent net increase in the number of reported murders and non-negligent manslaughters.” The findings run counter to the argument of the primary proponent of such legislation, the NRA.

On average, there are about 500-700 more homicides a year among the 23 states with stand your ground laws because of these laws: “One possibility for the increase in homicide is that perhaps [in cases where] there would have been a fistfight … now, because of stand your ground laws, it’s possible that those escalate into something much more violent and lethal,” says Hoekstra.

A tale of two farmers-food markets and what it means

I love fresh food markets. I had a fruit, vegetable, and fish market near me growing up, the old Market in the Loop, in University City, Mo. To this day I remain a loyal supporter of local food and local businesses that sell fresh fruit and vegetables. Today, these markets are very much at the center of the national health discussion on nutrition, healthy food, obesity, and politics. So I decided to examine this issue using two examples in Seattle–one where I shop and the other where I mostly people watch and occasionally will buy some food. (Please go below for my photo essay of both venues.)

For  the last decade, the public health community increasingly has been focussing on how to increase fruit and vegetable consumption by Americans, improve Americans’ nutritional intake, and address the complex systems that are making this country the fattest on earth. Research has shown that Americans still do not consume the recommended amounts of fruits and vegetables, and government research is showing that lower-income consumers eat fewer fruits and vegetables than higher-income consumers do.

According to research by public health experts, communities that lack full-service grocery stores and neighborhood food markets have less access to fresh fruits and vegetables. Since 2009, the CDC, in its list of strategies to reduce obesity, has called for making healthier food choices available in “public service areas.” Specifically, the CDC says local governments can make healthier foods accessible through policy choices and offering vouchers that can be redeemed for healthy food choices. This is happening nationally at farmers markets, where technology to read food stamps, or EBT, cards (known today as Supplemental Nutrition Assistance Program, or SNAP), is being made available to merchants so they can serve lower-income consumers.

The Food Research Action Center (FRAC) has called for increasing participation in SNAP; improving those benefit levels so lower-income persons can afford adequate diets, including healthier foods; promoting fruit and vegetable purchases with SNAP benefits, which is taking place; and boosting the access to healthy and affordable foods in “underserved communities.” To that end, the CDC is making available more than $100 million (chump change, really, when you compare that to funding made available to corporate farms through the U.S. Farm Bill) to promote policy, systems, and environmental change through Community Transformation Grants (CTG).  This is designed to “to reduce chronic diseases such as heart disease, cancer, stroke, and diabetes” — all major health issues that are also bankrupting our health care system and treasury.

A 2010 White House report on childhood obesity notes that in the last three decades, prices for fruits and vegetables rose twice as fast as the price of carbonated drinks, and a bump in the cost of fruits and vegetables relative to less healthy foods can reduce consumers’ desire to buy fruits and veggies, leading to unhealthy Americans. Pricing is of course a key issue impacting purchasing decision of lower-income consumers, among other factors. U.S. Department of Agriculture (USDA) research found that a 10% discount in the price of fruits and vegetables would increase the amount purchased by 6-7%.

So, yes, price matters a lot, along with access. Where I live (Seattle), the Farmers Market Alliance claims “the vast majority” of the fruits, vegetables, herbs, and berries are the same price or less expensive at farmers markets, especially with organics, than at conventional grocery stores (QFC, Fred Meyer, Safeway, etc.). The organization further claims that the quality and variety of its produce exceeds the quality sold at the chain grocery stores. The farmers market movement is truly national in scope, and a network of nonprofits like the Philadelphia based Food Trust is partnering with local farmers to promote farmers markets in underserved areas.

The Atlantic in May 2011 published an article noting that farmers markets were less expensive than supermarkets and provided better food. The article challenges the criticism that farmers markets catered to mostly wealthy white snobs who drive Subarus and Prius’s, and it argues that no formal research supports “this widely accepted contention, and the few studies that have been conducted call its veracity into question.” Of course the movement to support “local food production” and farmers markets has both national and local critics, including conservative bloggers, who call it a trendy cause. Some have blasted the use of electronic EBT card readers as a wasteful expense ($1,200 to purchase, $50 to lease).

The closest market to my home, about one mile away, called the Ballard Farmers Market, most definitely is more expensive than grocery stores and independently owned produce and grocery stores where I also shop in Seattle. Its clientele, based on my many trips there, is decidedly and stereotypically upscale, white or Asian (I’d say 90% white, 5% Asian, 5% other), and professional. I haven’t conducted a poll to actually verify this, but this corner of Seattle is not that diverse, and it is close to a neighborhood where homes fetch $600,000 and where condominiums are sprouting on many major intersections. No, I can’t afford to buy anything there, with the exception of a good bargain, like beets today ($3 a bushel of three). I have bought a few apples and heads of lettuce and other veggies in the past, but not much else — not salmon, not herbs, nothing. For my part, I grow some of my own food, pick some (like berries or tree fruit that abounds in Seattle), and wish I caught salmon like I did in Alaska.

I don’t begrudge the vendors there for selling produce at a higher price point, which shuts out low-income persons like me. (I may have a few university degrees, but I am by all measures very low-income now.) As one food blogger and jam-making blogger from San Francisco notes: “People selling at the markets have priced their products according to a wide range of criteria. First, many of the farmers who sell at markets are smaller operations than those who sell to grocery stores. Maybe they have 10 acres of land compared to 60 or 100 or 200 acres and rely almost exclusively on markets for income.”

I try to support my favorite produce store in Seattle, called McPherson’s Fruit and Produce, in Seattle’s Beacon Hill neighborhood. First, their selection is usually excellent–fresh but not organic food in season. I find their produce is fresher than most grocery stores. Their vegetables and fruits are always cheaper than any grocery store I visit, including stores with hefty supply chain advantages like Costco. They cater to a full spectrum of clients, and that clientele is more low-income and more ethnically diverse than what is found in Ballard. (Beacon Hill is much more diverse ethnically.) I’m as likely to see Hispanic, African American, immigrant, and Asian-American shoppers as I am those who look like me (white). However, McPherson’s is located about seven miles by car from my home, while the Ballard Farmer’s Market is a mile away, making it impossible for me to bike to Beacon Hill, and there are some serious hill and traffic issues. So I drive there, but usually combining outings and errands with a stop. I have been shopping at McPherson’s for years, during my previous and current stays in Seattle. I do not know if their model can be replicated in other cities–unique private owners, a great location on well-travelled road, proximity to distributors, an ability to attract shoppers with and without cars.

Perhaps instead of throwing all of our support into the farmers market craze, more can be done to help smaller businesses and producers. This would require the proverbial “upstream intervention.” For instance, our government tells people to eat five servings of fruits and vegetables a day, but is not providing the supports through federal legislation to make that possible. The White House Task Force on Childhood Obesity notes that by 2020, the country needs to boost the availability of fruits and vegetables by 70%, or 450 pounds per person a year (that’s an enormous pile of food by the way). It is not doing that now because of our dated, bloated Farm Bill.

Such upstream actions, to grow the intake of healthy food consumption, in a policy sense, have the biggest bang for the buck, compared to downstream actions. Many wise and smart persons who follow food and nutrition issues have long said that the pork-laden, decades-old Farm Bill needs to be overhauled to create true change. New York Times food blogger Mark Bittman notes “agricultural subsidies have helped bring us high-fructose corn syrup, factory farming, fast food, a two-soda-a-day habit and its accompanying obesity, the near-demise of family farms, monoculture and a host of other ills.” The farm bill, up for renewal in 2012, offers an agriculture subsidy worth $30 billion, $5 billion of which is direct payments to farmers. Conservative groups like the Heritage Foundation even blast this.

Bittman suggests that a revised Farm Bill–which I believe no one involved in policy-making believes can occur in the current political climate–should support farmers who at the moment now grow unsubsidized fruits, vegetables, and beans, while giving incentives to “monoculture commodity farmers to convert some of their operations to these more desirable foods.” This is food that would make us healthier compared to factory raised meat fed on subsidized grain, which is what our current system promotes. Bittman also calls for incentives to help medium-sized farms, those big enough to supply local supermarkets but small enough to care what and how they grow, compete better with corporate agribusiness.

Personally, I would love to see both farmers markets and McPherson’s in most neighborhoods in most cities. Right now, I’m going to stick with shopping primarily at McPherson’s, despite the inconvenience. And I’ll keep growing a garden where ever I live, too.

A massacre in Colorado and public health’s chilling silence to gun violence

Like many people in the United States and around the world, I was horrified by the news on July 20, of yet another mass murder in the United States involving firearms. We still do not know as I write this post the motives of the alleged suspect, a 24-year-old medical student named James Holmes. Nor do we know yet how he acquired the multiple firearms—a semi-automatic rifle, a shotgun, and a pistol, according to initial reports—used to kill 12 people and leave 59 wounded. Press reports quote police officials saying he bought his firearms legally along with 6,000 rounds of ammunition. We do know that neither President Barack Obama or GOP presumptive contender Gov. Mitt Romney uttered the word “gun” in their public comments the day after the mass murders.

Alleged mass murderer James Holmes in a photo published by many media sources.

For his part, New York City Mayor Michael Bloomberg, a billionaire who does not have to worry about his political career even if he is voted out of office and who can afford to defy special interest groups because of his great personal wealth, was quick to criticize both presidential candidates for failing to put forward plans to address gun violence, which is a concern of many elected officials in any sized city. “Soothing words are nice,” said Bloomberg, “But maybe it’s time the two people who want to be president of the United States stand up and tell us what they’re going to do about it, because this is obviously a problem across the country.”

Boston Globe columnist Derrick Z. Jackson wrote on July 21: “Gun control has so completely disappeared from debate that John Rosenthal, founder of the Newton-based Stop Handgun Violence, told me this week before the Aurora shootings: ‘I’ve never seen more spineless cowardice and lack of national leadership. Can you imagine the outrage if instead, 83 Americans a day died from hamburgers?’ Instead the conservative Supreme Court struck down urban handgun bans. Last year saw record gun sales in America, based on FBI background checks, as the gun lobby whips up utterly false fears about Obama taking people’s guns away.”

Such mass killings like we saw in Aurora, Co., now occur with alarming frequency in the United State. Where I live, Seattle, we have experienced a wave of mass shootings during the last two months, the most lethal at a University District area restaurant called Café Racer and elsewhere in the city on May 30, that left six dead, including the alleged gunman.

From a purely statistical perspective, firearm violence is a national health issue, if not a crisis. The Centers for Disease Control and Prevention (CDC) reports that the number of firearm homicides in 2010 in the United States was a whopping 11,493, or 3.7 deaths per 100,000. And the role of firearms in suicides was nearly twice that rate. The CDC for 2010 attributes firearms in the suicides of 18,735 persons in the country, or a rate of 6.1 per 100,000. All told firearms are linked to 30,228 deaths annually at last count. This is a truly staggering figure, and one that should have the entire medical and public health community demanding that moral and political leaders in this country develop a broad array of interventions to reduce these numbers, the way we mobilize yearly to dress in pink and run against breast cancer or embrace other campaigns designed to save lives and promote health. By contrast, Japan counted 11 homicides related to firearms in 2008, or a rate of 0.0 per 100,000 in epidemiological terms.

So why is the medical and public health community silent? Well, the answer is simple. It is about politics and money. Specifically, it is about the lack of federal money. And of course those who should be out front on this issue, including heads of hospitals and medical associations as well as faculty and heads of health sciences universities, are not demonstrating the needed moral courage to speak truth to the supporters of the NRA, business interests, and political groups, who exploit American fears about government and who seek to maintain the status quo politically through fear-mongering. That job is mainly falling to journalists and citizens groups mostly, as well as victims of crimes and their families.

The Nieman Foundation at Harvard University reported in February 2012 that the gun industry’s main lobbying arm, the National Rifle Association (NRA), has “systematically suppressed data about gun violence and the impact it has on Americans’ lives.” The  CDC in the early 1990s was releasing studies that found that guns in the home presented a greater danger to the occupants than potential home invaders. In response the NRA helped to prevent the funding of research on firearms’ death and injury. As a result, reports the foundation, the CDC appropriations bill the last 15 years has contained this language: “None of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control.”  And this year, the NRA successfully added a similar amendment to the National Institutes of Health (NIH) appropriations language.

The most well-known advocacy group that promotes strict gun regulation, the Brady Campaign to Prevent Gun Violence, was extremely critical of the CDC in 2011 for, in its words, requiring researchers financed by the CDC to give the CDC a “head’s up” when they prepare to publish firearms-related research. The CDC, in turns, shares that information with the NRA as a courtesy. “If the CDC is allowing the NRA to review its studies, it’s a deeply troubling practice,” said Brady Center President Paul Helmke. “To have a government agency open itself and its science to the influence of any interest group, particularly one whose policies undermine the safety of our families and communities, is improper, offensive, and unjustifiable. We need science that we can trust.”

One has to look no further than the Department of Health and Human Services’ (DHSS) exhaustive annual report called Health, United States, 2011. It lists the word firearms just nine times, and buries firearms data deep into the report, making that information effectively unimportant in the overall health assessment for the country. Meanwhile the introduction to that report profiles motor vehicle deaths (about 40,000 deaths annually) and does not profile death by firearms (suicide or homicide, which number more than 30,000 annually). One has to wonder how connected the funding ban is to this type of editorial decision by the DHSS and the CDC, which publish this document.

Of course many proponents of very limited gun control disagree firearms-related violence is a “health” issue. One pro gun blog, published by a group called AmmoLand.com, calls those who would choose to address firearms safety “elite gun banners.” (The those being criticized is the CDC.)

Which item does the CDC and many public health research universities consider more of a public health threat, and which receives more research dollars and scholarly attention?

What we are seeing, at least at public health departments through funding mechanisms, is a full-court press on chronic disease linked to unhealthy food like, oh fatty french fries. When it comes to clogged arteries but not loaded semi-automatic weapons, the CDC doles out millions dollars ($103 million at last count) through Community Transformation Grants. It continually baffles me how trained scientists who work in health care flat out follow the money to pursue research grants to get more people to eat fruits and vegetables and stop smoking while keeping mostly silent as people in their communities are gunning themselves down and others.

I never understood this during my studies at the University of Washington School of Public Health, where there is not one course where firearms issues are addressed as a public health priority, at least according to my understanding of the courses offered. I did a quick search on the UW SPH web site on July 21 and found just seven references to firearms, six to guns, and 233 references to obesity. (UW researchers were involved in a joint study published in 2012 about gun storage cabinets in Alaska, but one would expect more given the numbers.) But this is no different than at any publicly funded health research university that relies on large federal grants to sustain its faculty and facilities. Clearly this impacts what future public health leaders are taught. During my two years in my program at the UW SPH, which used problem-based learning and cases that touched on everything from obesity to smoking to HIV/AIDs to homelessness to influenza, our classes never discussed firearms violence as a public health concern. (Note, that changed this year for the class behind me thanks to comments raised by my cohort to faculty for suggesting new topics).

In my frustration today, I even wrote to my member in the U.S. House of Representatives, Dr. Jim McDermott, by clicking the on the topical area of “gun control” to submit my email to his staff. I know from past experience that federal lawmakers never read 99% of such emails, and their replies usually do not address the contents of constituent communications, instead relying on general policy statements that amount to little substance. Still, I felt compelled to express my continued disappointment at the failure of leadership that he and others are demonstrating on this health and policy issue:

“As a public health professional and as your constituent, I am writing today to ask if you can inform your constituents what you and your allies, including in the health community and law enforcement community, are planning to do in terms of a meaningful policy response to address the proliferation of firearms and in terms of providing funding to health professionals to begin to address this issue as a legitimate threat to the health of U.S. citizens? Can you provide any details about how you are working locally with groups seeking to have upstream and federal actions to begin to chip away at the powerful special interest groups that have hijacked the public debate on firearms? Are you seeking to challenge blue dog Democrats or Republicans who continue to communicate talking points that equate the Second Amendment of the Constitution with the sale of personal weapons that in no way correspond to the wording or intent of the Constitution or the intent of the framers of the Constitution? I await your leadership. If there is to be no action, than one wonders why there continues to be cynicism of citizenry about the leaders we elect to Washington to do the people’s business, not the business of special interests that are allowing weapons manufacturers to profit from the misery of innocent citizens wiped out by a completely controllable problem, were there true courage and leadership to face down the attack ads. People can lead, but well, so can the leaders we elect. I await to hear your strong voice.”