Vacations and Health Policy

Lately the President has been ragged on by critics for taking a vacation.  How dare he take a vacation while people are out of jobs, while there is a civil war in Libya, while the stock market is tanking, while it is Thursday?  Pretty standard petty politics.  George Bush also used to get hated on for spending too much time off at his ranch in Crawford, Texas.  At least the criticism comes from both sides.  Glad to hear we can be bipartisan about something!

There is a lot of irony with the comparison of our national attitudes about vacations and our record of active physical exercise.  Workers in the U.S. lead the world in on-the-job productivity. We take fewer vacation days than workers in most other nations.  The chart below shows government rules regarding paid holidays and paid vacations.  In almost all the nations included in the chart, workers are guaranteed paid days off; many countries have policies that translate into a full month of vacation as a basic benefit floor.  Now notice the U.S. on the far right of the chart.  Workers here have no such guarantee.  Of course, employers provide paid days off, but only as driven by the labor market.  At a time of high unemployment, companies are not pushed to be so generous.  For many reasons, we are the hardest workers in the developed world.   We are not lazy as a nation!

On the other hand, it appears we lead the world in obesity.  It is difficult to make international comparisons of this kind, because there is no common obesity standard; some nations actually measure height and weight in the population while others just gather self-reported survey data.  Nevertheless, one international comparison finds that about 34% of Americans over the age of 15 are obese, compared to other nations listed in the chart below:

So what can we conclude?  Americans are hard workers, willing to give more to employers than people in most other developed nations, and yet when it comes to putting effort into maintaining their health, they fall short.  Just like it is unfair to label the President a slacker for taking a vacation, it is unfair to call Americans unmotivated couch potatoes as a basic character flaw.  I think it is the circumstances that are different.

Another study compared what they called "transit trips" taken by walking, biking, or public transportation, looking at data from the U.S. and European nations.  Two things were noteworthy about their findings.  The first was that transit trips were inversely related to both measured and self-reported obesity: as the percent of trips taken by walking, biking, or public transit, compared to driving, increased, obesity declined.  The second finding is that U.S. citizens are dead last for transit trips.   Most of our trips are by car.

I think we are health-lazy, not because of character flaws or ignorance but because of public policies that don't support more active lifestyles.

Critical Thinking and Health Promotion

The other day I was talking to a graduate class about critical thinking.  This is a topic being increasingly emphasized in higher education in the U.S. right now.  Leadership and accrediting bodies have recognized that a lot of content information mastered by students 1) does not stay with them for very long and 2) has only limited shelf life as new information replaces the old.  One of the things that we believe is essential that students obtain from higher education, and even more from graduate education, is the ability and habit of thinking critically.  As an aside, American students often compare very unfavorably with Chinese students when it comes to standardized scores for reading, science, math, and so forth.  However, American students are better able to think critically because they are not cowed by the pronouncements of authority figures.  They seem to be unaware of constraining lines around problem solutions, to a greater extent than Chinese youth.  Unfortunately, U.S. students still may defeat this head start by being thoughtfully lazy. They are empowered to challenge conventional thinking, but few do so with much consistency, because they are preoccupied by popular culture.  What is this generation coming to?  Probably an age-old lament.

For many decades, we have assumed that students learn this along the way, just by spending time with academic thinkers (one hopes) and in the rarefied academic atmosphere.  Some students will be exposed to formal logic taught by philosophy departments, but most institutions do not require these courses.  It has become clear that colleges and universities must be intentional about instilling thinking skills.  There has to be a strategic and structured method, and it has to be part of general education.  Because this is fairly new, a teaching methodology is still emerging.  Professors are comfortable asking students to think about a problem, a concept, a case, and so forth, but that doesn't mean we know how to teach students how to think about thinking.  I did not feel very successful in the attempt mentioned above.

Critical thinking should be an essential derivative of education, and every young person should enter adult and professional life with a fully cultivated habit of challenging conventional ideas and unexamined assertions.  This is specifically true in the domain of public health and health promotion, both on the professional and the consumer side. Consumers are bombarded with marketing information for products that have health consequences, such as soft drinks or health-related products such as over-the-counter drugs or food supplements.  The volume and range of these products is so great that it is difficult for the public health agencies to give everyone the "right" answer.  Perhaps we can give people a framework for thinking critically about products and recommendations that may have an undesirable impact on their health.  We can help them discern whether a health web site is dubious or dependable, whether assertions for health value are factual or phoney.  There is lots of work to do here.

The other place where critical thinking needs to be strengthened is in professional practice.  The Patient Protection and Affordable Care Act (Obamacare) has a component directing the expansion of what is called "comparative effectiveness" research.  This is driven by the growing awareness that a lot of health care practices are based on limited or no solid evidence that they lead to improved patient outcomes.  A recent article in the Washington Post cites the example of a surgical procedure called vertebroplasty, designed to reduce chronic neck pain.  According to the Post article, 79,000 procedures are done every year, at a total cost of about $1 billion.  Yet, it has not been unequivocally demonstrated that these procedures work as promised.

What does this have to do with health promotion?  The same problems found in clinical health care, procedures and products that may not be effective but are driven by other considerations, are also found in health promotion practice.  The driving force in health promotion is usually not a profit incentive, but instead an unwillingness to break out of traditions, a belief that doing something is better than doing nothing, a lack of evaluation which might demonstrate failure, and settling for program investments that are inadequate, rather than pushing for more costly interventions that might actually have an impact.

Throughout my career, I have seen (and yes, participated in) many instances of health promotion programming that had no chance of being successful.  Learning and applying lessons from these programs is painfully slow.  We can do better, and a part of that is thinking more critically about what we do.  Unlike clinical care, where ineffective practice may be life threatening, our laissez faire attitude about effectiveness means that the public's health doesn't improve.  Comparative effectiveness needs to become a new normal.  For every program dollar available, what is the most promising way to invest it?  That is a critical thought.

Health Promotion at the State Fair

Last year at this time, I posted a blog about the Kentucky State Fair food innovation, the Krispy Kreme burger.  That burger got a lot of media attention in the local area, even though the concept was introduced a number of years ago in other places.  Nevertheless, the attitude in the public seemed to be that "foods" like this are just part of the charm of the State Fair.  The Health Promoters who raise concerns are just lifestyle Scrooges, who sap the joy out of life.  If you are reading this you will have no trouble spinning this a different way, to defend the value of healthier dietary choices.

This year the next big thing with Fair fare is deep fried Kool Aid.  I have no idea how one deep fries Kool Aid, but I'm betting it will get a lot of curiosity by consumers and the media.  I don't know the ingredients exactly, but web sources claim it consists mostly of Kool Aid, flour and water, and then of course oil absorbed during frying.  This is probably not the worst thing someone could eat.  Look at this link for other

examples of foods that race to the bottom of healthy food choices.See Outrageous Foods

To some extent this is an old story.  I've blogged about it a number of times, and there are lots of newspaper, magazine and TV stories about this, some lamenting, some celebrating.  However, I want to build a bridge to more generic health promotion ideas.

The U.S. Centers for Disease Control has a funding program for community health promotion programs, created as part of the Patient Protection and Affordable Care Act (Obamacare).  This program is called Community Transformation grants, and the concept is that a lot of what passes for health promotion is very superficial.  It provides some information and encouragement for lifestyle change but doesn't really have a basic impact on society and culture as a whole.  The scientific evidence base is not yet complete to really be transformative in the way our efforts influence society.  However, we will know we have arrived when outrageous foods  receive a widespread response of embarrassment or bewilderment, as though they were pornographic.  In society today, health promoters have degrees of defensiveness that makes them apologetic rather than proud of the service they provide.  To be transformative, we need to be asking not just "How do we get a fair goer to eat healthier," but "How do we change communities so that the junkiest of junk foods are no longer part of a viable business plan?"

Health Policy and Health Equity

For a few decades it has been recognized that health status is not evenly distributed across the community, and that this inequality is only partially based on individual lifestyle choices.  More often health disparities are greatly determined by social factors that establish patterns of poverty, housing, educational attainment, employment opportunities, neighborhood quality, community safety, and so forth. The unequal access to resources, opportunity and security is not always a function of racism and ethnic discrimination, but the effects tend to fall along racial lines.  It is not just that greater affluence almost always is associated with better health, though that is true.  It is also a function of the gap between rich and poor, the unequal distribution of resources. 

Here are some explicit examples of health disparities.  In the U.S., the infant mortality rate (in 2006) for white infants was 5.58, while the rate for black infants was 13.35, more than double.  About 8.2% of white children have asthma, while asthma is found in 18.4% of Hispanic children. In the 15-19 age group, white males have a homicide rate of 3.4, while the rate in Black males is 69.1.  Blacks have a coronary heart disease death rate of 162 while the rate in Asian/Pacific Islanders is 77.  About 12% of those with less than a high school education have diabetes; only 6% of those with more than a high school education have diabetes.  The rate of HIV infection is 7.2 for Asians, 8.2 for whites, 25 for Hispanics, and 74 for blacks.  While there are undoubtedly lifestyle choices involved in some of these examples, it is apparent that social factors are huge determinants.  Many times choice is limited by access to resources, which is socially determined.

Consider the following chart.  The legend and labels are too small, limited by the functionality of this blog space.  Nevertheless, it is still illustrative.  Each vertical line represents a U.S. state: Utah is the top line while West Virginia is the bottom line.  The dark portion of each line represents the number of healthy days per month reported by residents of that state.  States toward the top have the most healthy days; those near the bottom have the least.  The total length of each vertical bar represents income inequality, using a measure called GINI.  The higher the GINI score, the wider is the gap between rich and poor.  States near the top of the chart have the most equally distributed wealth; those at the bottom with the largest GINI scores have the most unequally distributed wealth.  The main point is that there is almost a perfect inverse relationship: the lower the income inequality the larger the number of monthly healthy days; the higher the income inequality, the lower the healthy days.

State-specific Gini index of inequality in number of healthy days and average number of healthy days --- United States, 2007. Source: Behavioral Risk Factor Surveillance System, 2007.

As it turns out, the U.S. stacks up poorly compared to most modern, developed nations in average life expectancy.  In many nations, men and women, on average, live longer than we do in the U.S.  However, our GINI score is also higher than that found in most modern nations: the gap between rich and poor is wider here than most other developed countries. Social and economic inequality makes us sick.  For this reason, many professionals believe that inequality must be one of the targets of health promotion if the public's health is ever to reach its genetic potential.

This brings us to the great ideological debate going on in our nation at the current time.  One side says that our society should reward hard work, ingenuity and risk-taking, that we should encourage independent initiative and avoid making people dependent on government benefits.  This school of thought puts its trust in the free enterprise system, and that if government do-gooders (like most health promoters) would get out of the way, people would naturally do what was in the best interest of them, and by extension, society as a whole.  The other side says that society and markets are inherently unfair, that people are not dealt equal cards.  Social and health inequalities will not correct themselves without organized community efforts, including public health and health promotion programs and policies.  Unless we intervene and regulate, wealth will be concentrated in fewer and fewer people, creating a rarefied oligarchy and a permanent underclass.  This is not only detrimental for the disadvantaged, but over time, is not good for society as a whole. 

What do you think is the right road?

What is a Health Policy?

When my father was a teenager, the family decided it was time to get their first car.  Not only did they not have a car, but no one in the family had ever driven before.  It fell on my father to be the designated driver.  When he was handed the keys, he just got behind the wheel and taught himself to drive by trial and error.  He had no instruction, no formal public information about driving safety, and most people he knew were no help because they had never driven either.

Over the last 100  years there has been great progress in controlling deaths and injuries related to driving.

This progress is surely in part due to education to help youth learn to drive safely, and a lot of public education designed to help current drivers be mindful of safe driving practices.  However, we have not stopped there.  Since my father's early days of driving, a lot of policy solutions have been applied.

Traditionally, a lot of public health programming has been either informing the community about various health issues, such as what constitutes a healthy diet, or offering a service, such as a flu shot or a screening test.  Less often, public health and health promotion has tried to achieve its goals with policy solutions.  What I want to talk about in this posting is what is meant by a policy solution.  The emphasis placed on policy solutions to improve the public's health seems to be growing, so it is important to discuss what this really means and why it is important.  Complicating the discussion is the fact that there is no universal definition of the term.  We always have to clarify what people mean when they talk about health policy:  what is included, what is excluded, what do other people call the same thing?

Sometimes a policy is a way to enhance behavior change, to make the healthy choice easier.  This is sometimes called the "default" option.  In a generic sense, default is what will happen unless you take special steps to avoid it.  At one time auto companies were making automatic seat belts that would circle your waist to within inches of the buckling ratchet.  The idea was that this system made it easier to use a seat belt than to decline.  Using the seat belt became the default option.  This was brought about by a policy solution.  Automakers were incentivized by federal regulations and market forces to find ways to make it easier for people to use seat belts, and so they built them into the vehicles coming off the assembly line.  Another example is the tension between stairs versus elevators.  In most public buildings the elevator is the default option by virtue of its featured location, while those wanting to use the stairs have to look around or ask directions to find them.  What if we had a sweeping stairway located directly in front of a building's entrance, while you had to search around for an elevator?  The stairs would be a default option that more people would choose.  Default options are determined by policies.  Health promoters will sometimes label this type of policy solution an environmental strategy, because the changed circumstance or setting makes it more likely that healthful living is supported.

Other policy solutions have been to construct cars that better protect riders, and we've learned how to construct highways and roads that provide a safer driving experience.  These types of policies do not have a behavioral component, but simply promote health without any individual effort.  This is sometimes also called an environmental strategy, again meaning that we have changed something about circumstances that promotes health and safety.  Prohibiting public smoking is a policy solution that can also be called an environmental strategy because people are passively protected from exposure to tobacco smoke.  A non-policy solution to this same problem would be using education to persuade smokers to not smoke near nonsmokers.  Often we combine policy solutions with supportive education designed more toward behavior and decision making.  About ten years ago, policies were put in place requiring the posting of signs by cigarette vendors, notifying customers that it was illegal to sell cigarettes to minors.  This was an educational message brought about by a policy.

Some policies are government efforts with a requirement or mandate on individuals. State governments use highway policies that prohibit people from exceeding a posted rate of speed.  The speed laws compel people to obey, with a threatened penalty for noncompliance.

Some other types of policy solutions are instituted by organizations.  For example, some employers have the policy of rewarding employees for accumulating miles of walking or running.  This is a policy solution by virtue of creating a social circumstance that makes it more likely that people will exercise, above what could be expected if those same companies just relied on educational messages and communicated encouragement.

Part of the recent emphasis on health policy is because experience and evaluation show that education and communication alone, even when done according to best practice guidelines, often fall short of achieving desired health outcomes.   On the other hand, some segments of society have become very sensitive about policies that mandate or prohibit actions by individuals.  They see this as taking away personal freedom in an effort to build a "nanny state," which is seen as a futile effort to immunize the world against all threats to health.  Health promoters have to balance the use of best-practice policies with conflicting values in communities.  Unless a community is largely supportive of a policy solution, research evidence for effectiveness is irrelevant.  For this reason, policy solutions are more complex to apply because of the multi-step process of identifying effective policies, persuading policy decision-makers, and preparing the community.  With educational tools, we send out motivational messages and people take them or leave them.  More often than not they leave them, unless they are supported with simultaneous policy supports.

Next time I want to discuss the interaction of health policy with health disparities.