You can get garden variety health advice from the daily newspaper, the "health" section of most book stores, and of course thousands of web sites. I'm hoping to present thought provoking and maybe change provoking thoughts about individual and community health. This blog is not just what to do about health, but how to think about it. I'm looking forward to an exchange of ideas with readers. July, 2010


Friday, December 31, 2010

Texting and Health Promotion Policy

Recently I’ve been reading research reports on the effects of cell phone use, particularly texting, on driving safety. Because of the rapid diffusion of cell phone technology and the practice of sending text messages, the research has been proliferating, but has not kept up with the diffusion wave.

The immediate reason for my interest in cell phone safety is that Kentucky has passed specific legislation prohibiting texting or e-mailing while driving for all ages, and prohibiting all driving cell phone use by those under age 19. The new rules went into effect summer, 2010; actual penalties begin January 1, 2011.

The rationale for Kentucky’s legislation and parallel bills around the country is that cell phones interfere with safe driving. In my searching I’ve discovered an obscure web site – http://www.distraction.gov/– maintained by the U.S. Department of Transportation. The larger issue is distracted driving, of which cell phone use is only one example. Distraction in driving can occur in three ways. Manual distraction is when a driver’s hands are doing something besides driving, such as using a phone, applying make-up, or interacting with a global positioning system. Visual distraction occurs when a driver is not looking at the road and surrounding traffic. This is a problem for most drivers when we look at things on the side of the road or inside the vehicle. Finally, cognitive distraction is the circumstance where drivers are thinking about something other than driving. Most drivers are unable to keep all of their brain power focused on driving, even if they are alone in the car. From the outline of types of distraction it is obvious that all drivers are distracted at times.

The forms of distraction come together in a perfect storm with texting. When a driver is conversing with a passenger, the distraction may only be cognitive, but not manual or visual. While all distraction increases risk for collisions, texting seems to present more danger than most other distractions, since it constitutes all three forms of distraction. The other factor that makes texting so concerning is that it is more frequently done by younger people, who have other characteristics that make them less safe as drivers.

Part of the reason many states are outlawing texting is that not only is it dangerous and worth trying to decrease if not eliminate, but the laws are effecting predominantly youth, who have very little political power and influence. If laws were to be directed more broadly at distracted driving, there would be more intense and more organized political opposition.

A final point is about the actual risk of driving while cell phoning. A lot of the research is done with driving simulators. Research subjects go through a series of typical driving challenges, with and without cell phone use. In general, these studies consistently show that drivers using phones perform more poorly, indicating higher risk for collisions. This science supports what most people would think intuitively. However, I wonder if it is more complex?

All cars come with radios, and operating and listening to a radio while driving is distracting from the task at hand. However, drivers also have collisions from fatigue and “highway hypnosis.” Those problems may be moderated by having a radio. If we compare perfect driving performance with radio-assisted driving, the perfect driving will have a lower collision rate. But if we compare real world driving with radio-assisted driving, the radio-accompanied driving may actually be better. It will be interesting to see in the future whether hands-free cell phone use actually has a safety benefit in real world driving.

At the present time we rely on public education to persuade people not to use cell phone functions while driving.  In addition, there is a growing body of policies trying to restrict and regulate drivers with cell phones.  It is too early to know what works and what doesn't.  Educational messages are fairly simple (Don't
!) so that makes communication easier.  However, cell phones and texting in cars have become ingrained in our culture, so this makes the behavior change process more challenging.  I think it will take a lot more people to have personal narratives about cell phone induced collisions before there is a critical mass of public credibility given to the issue.  As far as policy restrictions, support seems to be growing, but it is not clear yet what policies actually matter.

People are skeptical about enforcing cell phone with driving policies, and obviously that is a challenge.  However, that was and still is a concern regarding seat belt laws.  Forty years into the seat belt campaign, we still don't have universal compliance with the laws.  However, it is clear that the combination of educational messages and legal mandates have been effective in bringing seat belt habits to the level of a social norm, making our highways much safer than before.  We must work for that same outcome with drivers and cell phone use.

Monday, December 20, 2010

Mental Health and Public Policy

As I've discussed in earlier postings, health promotion applies tools to help individuals change their behavior, as well as applying tools to change communities and social circumstances to support and promote better health.  In recent years I've been persuaded that health policy is much more powerful than I've thought in the past, and probably more powerful, in general, than individual behavior change strategies.  There are lots of examples of the two prongs of health promotion with infectious diseases, chronic diseases, and injuries.  When we turn to mental illnesses, the picture is not so clear.

Mental illness can cause death, and in the case of suicide, about 30,000 in the U.S. per year.  Intentional violence can also be related to mental illness, but the mortality toll is less clear than with suicide.  Aside from those most severe manifestations of mental illness, the greatest concern is disability.  By some estimates, mental illness is the greatest cause of disability in the U.S., and probably also in most developed nations.  Surveys of mental illness estimate that in an average year, 30% of the adult population will have a mental disorder, including phobias, post traumatic stress, general anxiety, depression, and drug dependence.  More than half of cases are serious or moderate severity, though those classifications may be more art than science.  Nevertheless, something like one of every 17 adults will have a"seriously debilitating mental illness in a year's time.

Because of the population impact of mental disorders, they must be considered through the public health lens.  There has been interest in perfecting our ability to measure the nature and extent of mental disorders in communities, and to tease out the personal and social risk factors to guide interventions.  Unfortunately this research has not advanced to the point where there are simple recommendations for progress.  What I mean is, if you want to avoid lung cancer, try not to breath in smoke, particularly from cigarettes.  For most people that's all they need to know. 

For mental health, there are no simple guidelines. Physical and emotional conditions of early life certainly are important - if you have a choice, try to be born into a family with two parents present and emotionally engaged, middle class income, with an extended social network, including relatives, neighbors,  coaches, music instructors, and other supportive adults.  This statement is obvious, but also supported by research.  Our dilemma is how to assure that every child is chosen and every family is successful in its social mission of nurturing children.  We dable with this through public and private programs, but there is such a strong tradition of family independence in our culture that we frown on outside intervention, except in the most egregious cases, so that the safety net has lots of holes through which disadvantaged children fall.

A significant portion of health is socially determined, with correlations between a person's vitality and life expectancy and where they are located in society - physically, socially, and geographically.  Those on the bottom rungs of income, education and status typically will have the worst health, including mental health.  This is a self-feeding cycle, so that disadvantaged persons have the smallest chance of achieving the best health, and because of sickness and disability, are more challenged to move into higher levels of education and income.  Theoretically, this circumstance should be responsive to public policy tools and strategies, but as a society we have not made much progress in this regard.  We don't even agree on whether government has a stake, or whether individuals should be empowered only by market incentives.

Perhaps none of the above thoughts are new to most people.  I think it important to point out that mental health is to some extent a function of broad social policies.  If we believe that society and governments should seek to promote the best mental health possible for citizens, this will not take place unless we put in place policies which assure social conditions in which people can thrive in every way.  This will be a long, uphill climb.

Monday, December 13, 2010

Conservative Misunderstanding of Public Health

In some circles, the blame for our current troubles as a nation is all government, all the time.  The notion of government is synonymous with waste, fraud and abuse.  Every government employee, no matter how highly trained or hard working is reduced to "government bureaucrat."  There is also the widely held belief that government workers are more highly paid than private sector employees.  However, when factors such as education and experience are taken into account, it is not so clear that there is a disparity.  In fact, the pay disparity may be in the other direction - highly trained government employees are paid less than equivalent workers in private companies.  Since most of public health effort takes place in government, these attitudes and stereotypes matter.

Last week I had the privilege of interacting with a group of employees at the U.S. Centers for Disease Control.  I was there providing a training workshop, serving a group of about 50 civil servants in various specialties of public health.  I found them to be eager learners who are sincere about making an impact with their endeavors.  They were not unlike hundreds of public health workers I've either taught or otherwise associated with over the last three decades.  These are people who go to work every day, trying to contribute to the public welfare by decreasing tobacco exposure, diminishing community violence, protecting people against environmental toxins, and reducing the toll of infectious diseases.  At CDC as well as countless local and state public health settings, I have not found pikers sitting around trying to avoid real work until they can retire.

The facilities in which the training took place were not opulent, but in fact quite ordinary and basic.  That is also what I've found in hundreds of state and local public health offices and settings.  In fact, comparing my observations of these public sector facilities with my experiences in the private sector, such as in hospitals, insurance companies, and various corporations, the private sector sites have uniformly been better appointed, more spacious and well endowed.  While not all private facilities are luxurious either, it is just not true that public agencies are spendthrift for personnel or places of work.

Are there waste and abuse in government, including public health?  Most certainly.  Can you find public health workers who are unproductive, not serving the public good?  Without doubt.  But these things don't only occur in government.  There are workers in the private sector, including employees not in unions, who don't serve their employers well.  There is waste in every workplace, not just in government.  That is not to accept this as a good thing, but it is to reject the conservative narrative that fraud and abuse are unique to government. 

Public health agencies have a responsibility to be good stewards of the public's dollars.  Managers should expect evaluation of functions and accountability from employees.  This is good practice in every organization.  It is not hard to find examples of government services that are not very effective, and we need to always be trying to be better.  But, does anyone feel well served by insurance companies and banks?  Painting public health workers, as all government employees, as illegitimate is unfair, based on a lack of information.  There is the old expression, "What you're not up on, you're down on."  Because people don't understand public health, it makes an easy target.

And so I want to express my thanks to those mostly invisible public health workers who go about doing their jobs, trying to make healthier communities today and going forward into the future.  Those CDC professionals I met last week are a proxy for the public health workforce.  Many people don't know what they do, but those of us who do, must stand in their defense, with appreciation and support.

Thursday, December 9, 2010

Holiday Traditions and Social Change

As a preface to comments to follow, I want to make a full disclosure:  I really like eggnog, fruit cake (Yes, I do), many types of Christmas cookies, and look forward to sumptuous holiday meals.  Sometimes health promoters sound shrill and joyless.  THEY TAKE THE FUN OUT OF LIFE.  I don't believe that, but because we are often challenging people to stop doing things they enjoy, or start doing things they don't enjoy, it is easy to be the Grinch meets Scrooge.

Having set this stage, I also wonder why so many of our holiday traditions are not healthy?  By the way, I'm mostly thinking about the holiday cycle that starts in the U.S. at Thanksgiving and goes through New Year's Day, encompassing Hanukkah, Christmas, and Kwanzaa.  Other cultures and religions also have holidays, but I am less familiar with the health ramifications of, for example, Diwali or Ramadan.

In the U.S. and Western cultures, the "holidays" are marked with many social traditions, including special events, both religious and secular.  Our social definition of celebration usually includes eating too much, too rich, too often.  I challenge readers to visualize celebrating and merry making in ways that are truly health promoting.  Can you imagine sharing carrots to commemorate New Year's Eve?  How about the kids setting out a fresh pear for Santa?  Does a celebration have to be unhealthy?

The answer is that our culture, and maybe most cultures, have developed over hundreds and thousands of years, during which a variety of forces have come together to shape our traditions and our sense of what is fitting in a given situation.  So for example, culinary arts have developed to feature salt, fat, sugar, and alcohol - none of which are completely bad, but with typical culinary arts, the only thing important about food is to taste and look good.  Of course in the present day we have technology that enables more refined foods.  Up until the 20th century, it wasn't really possible to have a lot of high sugar foods, at holidays or any other time.

My point here is to illustrate that holiday food and drink customs and traditions are socially enmeshed.  They are driven by many factors, some not even conscious.  We can chip away at unhealthy practices by typical health promotion interventions, but to change the entire frame will require basic social change.  We can promote better understanding about how our holiday activities are related to over-all health, and illustrate some better options.  This is a common effort in many communities, but it doesn't have a huge impact because of the social background.

I won't say it is hopeless to think that the holidays could celebrate with health rather than unhealth, but it will be difficult.  On the other hand, there are examples of positive social change that led to health benefit.  I remember the time when it was customary for fathers to give cigars to their male family and friends at the birth of their children.  That custom has gone away, even though I have never heard of any direct efforts to discourage the practice.  Society has undergone basic underlying change with respect to our attitudes of what is appropriate regarding tobacco.  This profound change is possible with food, but it won't be simple or quick.

In the meantime, let's lift a glass to good health.

Friday, December 3, 2010

Health Information Overload

This week I attended a workshop to learn about EndNote, a software program designed to help with library research and citation management.  With EndNote you can search the world wide web for journal articles, books, and web-site based materials.  In the case of journal articles, those articles that are available electronically in full text can be downloaded onto your computer for future reference.  Once references are located, the software will capture the citation and incorporate it automatically into a new document, and will configure the citation into the reference style you are using, such as the American Psychological Association format; there is also a provision to automatically convert the reference style into the preference of hundreds of specific periodicals.  Truly an amazing tool.  My context is the memory of undergraduate days when we would spend a lot of time in the stacks of a library, writing notes and citations on index cards.  That sounds like the stone age by comparison.

As I was learning all the various functions of EndNote I was impressed again with the mind-boggling volume of intellectual material published every year.  Like all disciplines guided by science and research, health promotion tries to keep up with the latest consensus on effective practice.  That means being sure that we are promoting the most accurate health science information, but also that we are applying skills and techniques with the strongest evidence for effectiveness.  This is not new.  It is just that the volume of new information is expanding so quickly that few people can really keep up.  This is true for consumers, as well as front-line practitioners, and finally academics and researchers.  I spend at least half my workday in front of a computer, so that I have almost constant access to information sources.  I can't keep up, except in a few very narrow areas.  The pratitioners and consumers have almost no chance.

So what we have is a mixed blessing.  On the one hand, the accumulated knowledge is certainly far more than ever before, but the gap between what is actually known (somewhere, by someone) and what is put into practice by others is perhaps also greater than ever.  Since our capacity to learn is not growing, and the speed with which our brains can process information has not changed, solutions to this dilemma must come from the production and dissemination side.  EndNote is an example of something that can deliver more information faster and more efficiently, but I still have to find time to read those articles!

Somewhere in the future, we can hope there will be technological advances to couple our brain functions with new tools that can actually speed up the process of absorbing and synthesizing the flow of information.  Perhaps there is a way to break the mass of new information into new "cognition units," something other than traditional language-based words and sentences.  Maybe there will be ways to more efficiently filter the information that comes to us.  Professional journals are supposed to do that, but they are swamped by the tidal wave of scholarship being produced.  Magazines also serve a filter function, but the filtering used by the editors may be biased for commercial reasons.

For now, I have to live with the uneasiness that the graduates I proudly escort into careers will most likely fall farther and farther behind once they leave the university resources behind and have to function based on the tools they have and what seems right in the moment.  I'm hoping that the research enterprise will increasingly concentrate on dissemination, not just pumping out new science content information.  Perhaps social media will have a role in this, beyond the current focus on chatting about relationships and life's trivia.    There are giant leaps waiting to be taken.