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.

Are Swedes more beautiful, or do they just have a better public health system?

I have always thought about what makes some people look better than others — at the individual, ethnic, and national level. Having travelled on six continents, I have been able to test ideas and stereotypes—including my own—through personal observations.

Is "Jenny," who I saw on a YouTube video teaching yoga-type exercises, good looking because she is Swedish, and if so, what does that mean?
Is “Jenny,” who I saw on a YouTube video teaching yoga-type exercises, good looking because she is Swedish, and if so, what does that mean?

This all came back to me last night while I was surfing YouTube for a video on ski waxing, where I, yes, got distracted by what looked like a very healthy and attractive woman doing yoga. Instead of it being a yoga tutorial, it was a video published by two young Swedish women that is mostly a product of personal vanity and that natural desire to express one’s self. I believe their names are Jenny and Andrea, and they appear to have a preoccupation with their admittedly very good looks. I cannot fault them for that.

Yes, these two are very physically attractive. But I again thought about why? Why are many Swedish and other Scandinavian women I have met so attractive?

First, I do not ascribe to the idea of “national beauty” or the national ranking systems that have little scientific validity. Social and popular media are obsessed with the idea that Swedish women are among the world’s most beautiful. A dubious online source called Traveller’s Digest claims Sweden tops their list of countries with the hottest looking women. (The country’s men also rank No. 1). Such rankings amount to Internet silliness.

I traveled to Sweden in 1990 for about a week, staying with friends I met in India (Eva and Eva — yes the real names). I found many people I met there to be healthy and attractive, but not to an extreme. I did find an excessive amount of out of control binge drinking in the social circles my generous hosts ran with, particularly among college-age and slightly older Swedes. In fact, globally, I have found few places that matched the excessive drinking I saw all over Sweden.

I also have seen Swedes globally, and in general many do appear more fit and healthier than the typical American, who rightly has earned a reputation as being overweight and thus unhealthy, and therefore unattractive in the eyes of many. Such data is borne out by national health statistics, as America is the fattest country on the planet, and because of that, my country does not have the reputation as Sweden does for the hottest men and hottest women, I think.

One of the most ubiquitous stereotypes of nationalities is that of "hot" Swedish women--perpetuated by photos like this one.
One of the most ubiquitous stereotypes of nationalities is that of “hot” Swedish women–perpetuated by photos like this one.

Globally, Sweden does very well in terms of health rankings and public health investments. Sweden scores highly in terms of life expectancy from birth, ranking No. 16 among all countries (81.8 years). Its Nordic neighbor, Norway, ranks 25th (80.32 years). The United States fares worse than both, and Jordan, and New Zealand, and, well, 50 other countries, at 78.5 years. By comparison the much poorer Cuba, with a vastly lower standard of living (less than 20% of the United States per capita), ranks No. 60, with a life expectancy of 77.9 years.

In 2010, according to the World Bank, Sweden spent 9.6% of its GDP on public and private health, including preventive and curative services, family planning activities, nutrition activities, and emergency aid designated for health but not water and sanitation. Norway spent nearly the same amount, or 9.5%, while the United States was staggeringly inefficient, spending 17.9% of its GDP, and the trend is getting worse.

The socialist and undemocratic Cuba, which invests heavily in public health for its population, spent a mere 10.6% of its GDP, but had nearly the same life expectancy per person as its mighty northern neighbor, America. So even though the United States spends nearly twice as much as these three countries, it does not have results to show for it.stats for four countries income health obesity

Such discrepancies are frequently cited highlighting how grossly inefficient U.S. health care is compared to countries with strong government-backed and financed health systems.

But do such investments have anything to do with physical appearance, and thus beauty?

Well, expanding waist lines and bulging bottoms, which nearly most people globally do not view as physically attractive, seem to indicate that Americans are likely to be less attractive than Cubans, Norwegians, and those stereotypically “hot” Swedes.

The International Obesity Task Force estimates that, globally, 1 billion adults are overweight (BMI 25-29.9 kg/m2) and 475 million are obese. In the United States, two-thirds of all residents are obese or overweight. The United States is the world’s heaviest country per person–a dismal and frighteningly scary statistic for our healthcare system and for future incidence of many of our top killers (cancer, heart disease, as well as diabetes, though further down the list).

So why, say, is Sweden doing better than many countries and the United States.

For starters, everyone in Sweden has equal access to health care services under a decentralized, taxpayer system. The Swedish Institute reports that every city council “must work to promote good health for the entire population.” Again, this is a vastly different value system than the United States’, where taxes are viewed with increasing hostility by the political right and where individuals are still, for the most part, considered responsible for their health.

This photo published by the Swedish Institute highlights a view of health, from youth to old age, and by most measures, Swedes are healthier and live longer than Americans.
This photo published by the Swedish Institute highlights a view of health, from youth to old age, and by most measures, Swedes are healthier and live longer than Americans.

In Sweden the responsibility for health and medical care is a shared responsibility of the central government, county councils, and municipalities. The country’s Health and Medical Service Act regulates the roles of county councils and municipalities, and it gives local governments freedom in this area, while the central government sets principles and guidelines for health and medical care.

What’s more, Sweden’s maternal mortality, another key public health indicator, is among the world’s lowest: 2.74 in 1,000 babies and less than than 1 woman out of 100,000 die in birth. “Swedish maternal care is often highlighted as a success story in international contexts,” boasts the Swedish Institute. By comparison, the United States infant mortality rate is 6 per 1,000 (bested by Cuba’s 4.73 per 1,000).

So in the end, you have a country that invests more in its people and in the health of its people, who likely have a good chance of being active and also avoiding stigma associated with excessive weight. It’s not so much that Swedish women, like Jenny in the exercise video, is anything extraordinary, though she is very attractive because she is healthy. She is, perhaps without her full awareness, the recipient of extensive investments in her education, her health from cradle to grave, and a social contract that values the well-being of the population.

The International Obesity Task Force published this map of obesity rates globally; some data likely is missing for African nations.
The International Obesity Task Force published this map of obesity rates globally; some data likely is missing for African nations.

And how do we react when we see Swedes, on YouTube or traveling abroad, or in business or education settings? We react positively.

An August 2012 story published in Psychology Today (“I’m Successful Because I’m Beautiful”– How we Discriminate in Favor of Attractive People) highlighted some frequently cited studies on how specific physical traits are rewarded.

The article quotes Dr. Gordon Patzer, who reportedly conducted three decades of research on the topic and found that human beings are “hard-wired” to respond more favorably to those who are attractive: “Good-looking men and women are generally regarded to be more talented, kind, honest, and intelligent than their less attractive counterparts.”

Still, obesity is afflicting even the Nordic countries, which has universal health care and strong safety nets. A 2010 study by Kirsti Matlerud and Kjersti Ulrisken in the journal Patient Education and Counseling (“Norwegians fear fatness more than anything else”–A qualitative study of normative newspaper message on obesity and health) looked at how newspapers in that affluent country sent messages on body weight. They found in a public survey, when people were asked what health problems they would like the health authorities to give priority to, obesity ranked highest, and then followed by care for the elderly, cancer, psychiatry, and cardiovascular disease. They also reported a general attitude of fatness being associated with being lazy and irresponsible.

So yes, they do care about their looks in Nordic nations and discriminate against overweight persons, much the way we do in the United States. They just do a better job of ensuring their population stays healthier. Jenny and Andrea have reaped the benefits and get the added benefits of being viewed as  attractive and being seen more favorably than those who have not had a national health system ensuring its population has the best possible chance of being healthy.

Taking the pulse–do exercise programs get kids in shape?

New York Times blogger Gretchen Reynolds, in her Oct. 3, 2012, piece, Do Exercise Programs Help Children Stay Fit?, profiled a recent British journal article that shows such weight-reducing and health-promoting efforts from the past two decades have flopped. (Scroll below to take a quick one-question pool on this very question.)

Citing the study published by Brad Metcalf and colleagues in the August 2012 edition of the journal BMJ (a journal accessible to all users), Reynolds reports that the authors found that “programs almost never increase overall daily physical activity. The youngsters run around during the intervention period, then remain stubbornly sedentary during the rest of the day.”

Two decades of interventions to help kids move more and weigh less may be failing.
Two decades of interventions to help kids move more and weigh less may be failing.

The British team of researchers from the Peninsula College of Medicine and Dentistry in England found 30 acceptable studies that met their criteria for examining if exercise interventions for kids work. The articles reviewed were published between January 1990 and March 2012. According to Reynolds, the programs simply failed to do what they were supposed to do: get young people to move more.

The article said their data covered 14,326 participants–6,153 with accelerometers that measured physical activity. The authors concluded that interventions “had only a small effect (approximately 4 minutes more walking or running per day) on children’s overall activity levels. This finding may explain, in part, why such interventions have had limited success in reducing the body mass index or body fat of children.”

An accompanying editorial  by Sally and Richard Greenhill notes that current United Kingdom guidelines state that all children and adolescents should have 60 minutes of moderate to vigorous exercise a day. And in the United Kingdom, only a third of boys and a fifth of boys are meeting those guidelines. In the United States matters are worse, and kids’ levels of inactivity now ranks as harried parents’ No. 1 concern, according to an August 22, 2012, USA Today story. Yet, parents appear to be a big part of the problem, too, along with ubiquitous and highly, highly, highly addictive technology. Nearly six out of 10 children spend less than four days a week playing outside because “parents find it more convenient to spend time in front of a television or computer.”

Times writer/blogger Reynolds quoted Frank Booth, a professor of physiology at the University of Missouri-Columbia, who worked on the meta-analsysis in the BMJ: “So if structured classes and programs are not getting children to move more, what, if anything, can be done to increase physical activity in the young? It’s a really difficult problem.”

Such a finding begs the question: Do interventions to promote physical activity work, or are they a waste of time and resources?

Maine’s Efforts: Cutting Edge or a Good Idea Needing a Makeover?

The Let's Go program in Maine is one of many in the United States trying to get kids to exercise for an hour daily.
The Let’s Go program in Maine is one of many in the United States trying to get kids to exercise for an hour daily.

One influential program, that combines exercise with nutrition and is being duplicated across the country, is the Let’s Go! 5-2-1-0 program from Maine. This stands for:

5 – fruits and veggies,
2 – hours or less of recreational screen time,
1 – hour or more of physical activity, and
0 – sugary drinks, more water, and low-fat milk [editorial note, I find the promotion of milk as a drink for kids questionable, given the inordinate influence of big agri-business on the U.S. Department of Agriculture and the availability of other fortified, non-dairy drinks].

Let’s Go! founders claim the program is successful and is grounded in three principles: 1) changing environments and policies; 2) consistent messaging across sectors–like “5-2-1-0”; and 3) approaches that use science and are recommended by the medical community.

Places as diverse as Kentucky and Hawaii are attempting to duplicate this program, despite apparently non-conclusive evidence of its efficacy.

Maine launched the program in response to the obesity epidemic (as of 2005, more than 60% of all adults in Maine reported being either overweight and 36% of kindergarten students, 26% of 6th-8th graders, and 29% of 9th-12th grade youth were reported being overweight or at-risk for overweight).

According to the program’s own evaluation of its efficacy tackling issues such as weight, the prevalence of overweight and obesity among children decreased from 33% in 2006 to just 31% in 2009 and was not statistically significant. However, among females, between 3 and 5 years, a smaller proportion were overweight and obese in 2009 compared to 2006 (25% vs. 31%). In short, this confirmed the findings from the BMJ study.

But what do you think?

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.” 

Good food is not expensive or hard to cook, and tastes delicious

Pasta and vegetarian red sauce: nutritious and delicious, and not expensive
Pasta and vegetarian red sauce: nutritious and delicious, and not expensive
Lentils can taste yummy with curry, garlic, and turmeric--and they are super duper cheap and easy to cook too
Lentils can taste yummy with curry, garlic, and turmeric–and they are super duper cheap and easy to cook too

During my two years of public health studies at the University of Washington School of Public Health, I and all students in the programs have been exposed to our growing public health crises concerning chronic disease, the obesity epidemic in the United States, and our apparent inability to turn the tanker on these problems.

A fundamental debate to these problems is whether individuals or systems are responsible, and to what degree. A lot depends on your political point of view. Many persons who could be classified as liberals or progressive and perhaps Democratic attribute problems to complex processes, like the role of the Farm Bill in creating subsidies that have led to the overproduction of unhealthy processed foods. Those who might be considered conservative and Republican frequently point to the responsibility of individuals in making food choice decisions and controlling their level of physical activity.

I’m a firm believer that our built environment plays perhaps one of the largest roles, along with cheap energy (measured by pump and meter prices) and the ill effects of our corporate food production system. However, I also believe that people are capable of making smart food choices, and do not do that. When we have discussed “behavior change theories” in my class, I am led to believe that people must go through many stages of change before they can succeed, in say not eating junk food or in cooking food. I have challenged these ideas in my classes, and my peers in my program literally laughed at my face when I criticized this model and suggested that, yes, individuals actually can choose to eat good food, if they wanted to.

While I think the behavior change model has validity, I do not think that wipes clean the responsibility of individuals to turn off their TV for 4-6 hours a day (the average in the U.S. according to research), get out and take a 40 minute walk, and spend an hour cooking something cheap, healthy, and nutritious, like lentils and vegetarian red sauce with pasta. In many ways, I think such ideas are anathema to current public health models and thinking at respected institutions like the UW SPH (my school). I find myself swimming against the current as I am being taught how we can turn the tide on the health crises that are bankrupting our country and that are transforming us into a nation of unhealthy, overweight, gasoline-addicted citizens who apparently can do nothing to control the destinies of their own bodies.

Even though many poor persons cannot access completely healthy food, nearly everyone can likely get the following food items, even at bad food stores: red sauce, dry lentils, pasta, and perhaps a few vegetables (onions, carrots, maybe even a green pepper) and garlic. Spices cost extra. I have priced out what it costs me to make a large batch of red sauce and pasta for 10 meals: usually from $12 to $15. A batch of lentils, cooked into a soup or thicker stew, will cost less, perhaps at most $10 to $12, figuring the cost of rice or tortillas, which is what I eat them with. These prices can vary by location. Both dishes take no more than one hour to cook, if you soak the lentils for 24 hours or longer. My thesis completely contradicts arguments of respected faculty at my school, who suggest that lower-income persons eat high-calorie, low-nutrition food because it is a better dollar value per calorie (I  reject this idea).

And what do you get when you cook them? Healthy food. Lentils are high in fiber (prevents coronary disease,) vitamin B6 (highest in any plant food), protein, and iron. And they help with digestion. Lentils also are practically fat free. As for vegetarian red sauce (I do not use meat), it is a staple of the so-called Mediterranean food pyramid, which is associated with much less risk of coronary disease, longevity, and good health. Yes, you can eat well, eat cheaply, and live better . But that requires you first to turn off your TV, take the time to cook, and realize that, yes, you are in control of what you put in your mouth.