Health Promotion In Your Face

Recently ABC news had a story about public school students complaining because the cafeteria lunches are too healthy and too low in calories.  A whole serving of new school lunch policies has pushed food service directors to provide less fries, pizza and chicken nuggets, and more fruits, vegetables, and low fat milk.  This comes on the heels of most schools eliminating junk food vending machines, and some schools putting stricter limits on food sales (such as bake sales) as fund-raising tools.  While the lunch lady was never the most popular person in school communities, this raises a whole new regimen of rancor.  Some students are resentful that they can't have burgers and fries for lunch every day, while other students are aggravated by what they see as force-feeding of vegetables.  On top of these conflicts, some conservative parents object to the "nanny state and nanny school" interfering with the views and traditions of parents who believe they should be the driver of nutrition for kids.  The health promoters behind the push for schools to be focal point in the fight against obesity perhaps feel isolated and unappreciated at best.  It is much easier to produce and disseminate congenial PSAs, encouraging families to eat more fruits and vegetables.

Also this week there has been news coverage about a media campaign produced by Blue Cross / Blue Shield of Minnesota, highlighting the influence of parent's bad food habits as a developmental influence on kids.  The campaign has become controversial because it is seen by some to shame and humiliate adults who are overweight.  The producers felt that the extreme urgency of the obesity epidemic justified pushing the envelope of social decorum because many of the media messages used in the past were not working.

The issue is not a new one.  During the 50 years of the anti-tobacco campaign, we've seen media messages making women blame-worthy for smoking while they are pregnant.  We've also seen media pieces connecting cigarette smoking with male impotence.  Such messages don't rely on guilt or shame, but are  certainly provocative, deserving at least a PG-13 rating.  Other messages have overtly associated marijuana use with a somnolent lifestyle leading to a dead end - a message some would find insulting or offensive.

So the question is, do health promoters have an obligation to be nice?  How do we deal with the tension between respect and cultural sensitivity and the driver of our profession, helping people obtain and maintain better health?  This is a professional dilemma shaping our identity.  It is also an ethical issue, regarding recognizing a line demarcating effective practice versus guilting and manipulation.


Why do health promoters sometimes use these in-your-face tactics?  Sometimes it is a lapse in judgement to resort to controversial approaches, because the epidemiology screams so loud, whether it is obesity, smoking or HIV prevention.  Sometimes these messages are intentional as a way to break through the media clutter.  Only provocative messages get more than a nanosecond of attention some times.  In addition to grabbing peoples attention with health promotion ideas, controversial messages and approaches have a chance to create "buzz" leading to further discussions at home and at work.  Most of the time, people talking about a health promotion theme is a good thing, moving people ahead in readiness to change.

Of course we have an obligation to treat clients and communities with respect and compassion.  Overweight children and adults are part of a cultural minority group, facing their own set of discrimination and ridicule.  We certainly don't want to perpetuate this, but neither do we want to be a Nero, fiddling while Rome burns.  Much thought and wisdom are required.

Health Promotion Behind Bars

In the last few days, two unrelated cues came my way, both inspiring me for a blog posting. In my building we have a closed-circuit information TV screen system, that scrolls through announcements, birthday notices, a vocabulary “word of the day”, and inspirational quotes. This week the quote was from Nelson Mandela: “It is said that no one truly knows a nation until one has been inside its jails. A nation should not be judged by how it treats its highest citizens, but its lowest ones.” Of course Mandela has credibility as a first-hand witness.

The other item that stopped my forward progress momentarily was an op-ed in the Washington Post, by Elton John, regarding the treatment of HIV positive individuals in U.S. jails and prisons, particularly in Alabama and South Carolina. John documents examples of unfair treatment experienced by these prisoners, particularly in those two states.

The Mandela quote and the John article both come together on the topic of prison health. Most societies make some effort to provide medical care and more generally, ethical and humane treatment for those persons incarcerated.

In all developed nations there is a social agreement, supported by some legal safeguards, that people locked up by society should be provided with basic resources to support life: air, food, shelter from the elements, personal hygiene facilities, and medical care. The principles that provide a rationale for the provision of these and similar services are several, but general in nature. They create an expectation for these basic provisions, but don't specify components and extent of services. For example, we agree that prisoners should be fed, but at what quality level? There is a lot of distance between the most inexpensive, barely adequate food and first quality protein, fresh produce, and whole grains. In most places this is simply a short-term budget issue, managed by bureaucrats in the correctional system, with no thought to long-term implications. However, society has a stake in these decisions, in the same way that all have a stake in the public school system, even those who don't have school-aged children.

Incarceration is mostly about punishment for misdeeds, some of which are truly heinous. However, there is a hope, for most prisoners, that prison time is the first step in personal rehabilitation. Spending time in a "correctional" institution is supposed to get people back into the community, making contributions in a pro-social way. Prison programs are judged, in part, by their recidivism rates: the frequency with which freed prisoners return with subsequent offenses and sentences. While there may not be much evidence that health promotion for prisoners decreases the recidivism rates, we can construct a limited extrapolation: healthier children perform better in school, and healthy workers are more productive for their companies.

The dilemma is how to apply health promotion practice principles within the unique setting of corrections. Prisoners are an interesting challenge for education programs. It can be predicted that the average resident of a state prison was not a model student. A large portion (23 %) of prisoners report learning disabilities. We would expect health literacy to be a particular concern, but this is only speculation because of a lack of definitive data. Prisoners have limited control over their health behavior, compared to other adults. For example, opportunities for a physically active lifestyle are narrow, and healthy nutritional choices are confined to foods provided by the warden. They also have limited opportunities to secure social support, and health promotion professionals will have limited prisoner exposure time and a much smaller range of tools. For example, social media would not generally be a feasible tool in the prison population.

The other type of intervention, policies, are also uniquely challenging. In this sense, prisons are parallel to corporate health promotion. Companies will only implement health promotion, including health policies, if there is real evidence that the investment will reap a return of increased productivity and improved profit. In the same way, prisons would be interested in health promotion only if it had a desirable impact on a few key things; 1) Does health promotion for prisoners have a positive impact on recidivism? 2) Does health promotion make for more contented, easily manageable inmates? 3) Does health promotion save money on healthcare, which amounts to billions of dollars nationwide?

The above questions represent a research agenda. Many answers are yet to be found. In the end, we have to find consensus regarding what is appropriate treatment for incarcerated criminal offenders. Does their criminal penalty also include having their medical problems neglected, no provisions for health promotion, and to be victimized by sexual assault and violence? President Mandela is challenging our national conscience, but for most people, prisoners are locked away where we don't have to glance at them. Perhaps it is time to think about health for all, including those on the other side of bars, walls and razor wire.

Life by a Thousand Cuts

There is historical evidence that in ancient Chinese culture, continuing up to as late as 1905, a method of execution was used called "death by a thousand cuts."  In this blog I want to celebrate life and health, not death, and so choose not to elaborate on a method of capital punishment.  It is enough to say that the method relied on the cumulative effect of very small injuries, none of which was life threatening, but the process would build until the cumulative effect of a "thousand" small wounds ended with someone's death by hemorrhage and shock.  I'm using this as an analogy for health policy and health promotion.

According to news reports, this week the New York City Board of Health is prepared to enact a limit on the sale of sugared soft drinks, with a cap of 16 ounce serving sizes.  If the proposal is approved, fast food workers will only be able to say "Can I moderate-size that for you?"  Not exactly a zippy sales line. The local health code rule change was first announced in May of this year, and has been debated vigorously since.

One of the arguments against limiting serving size is that it won't matter, that people will get too many calories in many other ways, and in fact, they can just buy 2, 12 or 16 ounce beverages, effectively doing an end run around the rule.  It is not hard to find oppositional arguments that have face validity, and in fact, the sugared-beverage restriction cannot be called an "evidence-based" strategy.  Here is what is known: 1) Obesity is increasing dramatically, and the consequences for morbidity and economic impacts will be great; 2) sugared beverages are a huge contributor to excess calories in people's diets; 3) when people are given larger portion sizes, they eat and drink more; 4) if there were no other changes in diets, people drinking a few less ounces of sugared beverages would lead to substantial weight loss in the population.  All of these are persuasive points, but don't unequivocally resolve the debate.

From a health promotion perspective, it is worth trying all kinds of strategies for big public health problems.  Here is a chart that portrays many of the interventions used to limit tobacco use in society.

Many, perhaps most of the items in the chart have only a marginal impact by themselves, but taken together, the impact is to create a social environment in which non-smoking lifestyles are reinforced and encouraged at every turn.  That is where we are trying to take society with respect to obesity.  Sugared beverage restrictions in isolation may have limited effect on calorie consumption, but in combination with "thousands" (well maybe dozens) of other strategies, both policy and persuasive, we can create community contexts where healthy food and beverage choices are the norm.

This will take time, but only long-term change will be sustainable.

Prevention and the Urgency of Now

Recently I've been reading The Emperor of All Maladies: A Biography of Cancer, by Siddhartha Mukherjee.  In the book, the author recounts the long struggle to perfect surgical and pharmaceutical treatments for cancer.  For example, there was a long slog of decades, working out "best practice" for breast cancer surgery.  It became clear that removal of observable and limited tumor growth was not effective in stopping the progression of cancer in women's bodies.  On the other hand, how far should surgeons go to take out all the tendrils of the out-of-control cells?  For many years "radical" mastectomy was the gold standard.  This procedure hideously deformed and disabled women; it would be many years later before randomized clinical trials showed that extensive cutting and disfigurement did not achieve better outcomes than less invasive procedures.  Nevertheless, the researchers were driven by the cruel reality of watching their patients die.  That experience had a way of focusing people.

Mukherjee also describes the long, and unfinished, battle against childhood leukemia.  Clinical researchers had to inflict misery associated with cancer cell-toxic chemotherapy on their young patients and their parents.  For many early chemotherapy regimens, the oncologists would see short term improvement, only to be followed by the relentless return of metastasis and death.  This agony and ecstasy of medical treatment research drives a pursuit of better.  Clinical researchers don't want to face another dying child, but want for all the world to reduce and remove illness and suffering.  Some medical research is about corporate profits while some is doing battle with the biblical "Four Horsemen of the Apocalypse": pestilence, war, famine and death.   Sydney Farber, described in Mukherjee's book, was of that school - sleep deprived to save one more child.  The misery and pain among the most desperately ill serves as a driver of efforts to find a cure.

In contrast, the enterprise of public health and health promotion is about preventing disease.  We want bad things not to happen, even though it will always be hard to be recognized and appreciated for things that never occurred.  So here is the contrast:  clinical care sometimes receives deep, genuine gratitude, not to mention compensation, for getting sick people well.  Public health can help millions of people never need that cure, but most people never know how their lives were blessed by that effort.  This part of the story is old news.  Public health and health promotion is undervalued by the public and by the clinical medical establishment.  So be it.

However, I want to bring the discussion back to seeking cures for cancer and the whole range of human ailments.  Those cures came quicker than they might have because of the emotional trauma associated with very serious diseases.  There is an exhaustion that comes with seeing people die, and it makes many researchers resolve to speed the day when successful treatment is just a routine matter.  In public health, and maybe especially in health promotion, because that drama and emotional trauma is usually not there, practitioners are lulled to sleep, content to do what they do, because they have always done it.  There is not the personal and social pressure to improve.  Medical crisis pushes for change, while mediocre results of prevention programs go unrecognized, just another banal government program, nobody expects, nobody cares.

If we could find a way in health promotion to make our unfulfilled  prevention targets more personally costly, perhaps progress would come at a more rapid rate.  Yesterday CDC reported that 36 million American adults have high blood pressure that is not controlled, and that 1,000 people per day die from the consequences of high blood pressure.  If we could make those statistics hit us like a deathly sick child does an oncologist, fewer health promotion practitioners would settle for the status quo.  Perhaps it is time for health promoters to be sleepless late at night, worrying about the obesity we are not preventing.

Policy and Freedom

Recently I was reading a mission statement from a nearby local public health department.  Their mission, although they labeled it their purpose, was to "change the public's health, one person at a time." Without being hateful or combative about it, that mission entirely misses the concept of public health.  The public health enterprise organizes itself to impact whole communities, whereas clinical health services are designed to efficiently serve one patient at a time.  We need both doing what they do best, not both systems doing the same thing.  It is dismaying to me that even among health promotion and public health professionals, there is still lots of fuzzy thinking about what we do.  Albert Einstein is quoted as saying "Perfection of means and confusion of ends seem to characterize our age."  It is still true, except we are also confused about means.

So what are we good at, and how can we have the greatest impact on the public's health?  A change has come about in the way we think about public health interventions. Whereas in all the years going back to at least the 1960s, the social and behavioral sciences component of public health has been about designing health behavior change programs.  The toolset for this was education and communication programs for communities.  More and more, leadership (such as at CDC) is moving away from traditional community programs.

The coin of the realm is now policy and environmental strategies.  Thomas Frieden, Director of CDC, asserts that education and counseling are largely ineffective, to be used only when interventions lower on the food chain, or to switch metaphors, more upstream, are unavailable.  While I don't fully agree with Director Frieden, one cannot argue that policy does not have huge potential to promote the public's health, and to do it more effectively and efficiently than behavior change programs.  In my view, we need to do all of the above, because the complexity of public health problems requires it.  Nevertheless, I want to discuss the policy emphasis in the current social and political climate.

Policy solutions to public health problems often require ending or curtailing actions on the part of individuals and organizations, such as businesses:  The prohibition to sell cigarettes to those younger than 21 is an example.  Policy solutions sometimes dictate individuals and organizations bear a cost as part of the policy: Requiring restaurants to provide calorie facts on menu boards is an example.  Actions such as these create an entirely different response then the communication campaigns that rely on people making better voluntary choices based on information provided.  Nevertheless, in the not too distant past, people were much more comfortable with government public health agencies using policy tools.  There was a sense that we accept some personal limitations for the greater good.  That social ambiance seems quaint and naive in 2012.

As represented by rhetoric coming from partisan campaigns and positions articulated by political parties and advocacy organizations, there is an ascendency of the view that personal freedom trumps every other value.  Large segments of society bridle against using the power of gevernment to make policies for enhancing the public's health.  Those of this persuasion resent any limitation of their freedom and reject the legitimacy of prosocial taxation and spending by governments.  They are skeptical of the notion that government can be a valuable tool by which we all work together to solve problems for everyone.  Freedom is the new byword, code for shrinking government (including public health) and stripping away its power.

We obviously suffer from poor timing.  Just at the time when the public health enterprise is putting great stock in policy solutions, there is a perfect storm of opposition to the legitimacy of government.

This emphasis on policy formation and advocacy is slowly moving into the Schools of Public Health and academic training programs.  In the current environment, we need to be teaching not only the mechanisms and values of policy solutions, but also how to be skillful in confronting the deep and apparently growing resistance to any expansion of government action.  In my experience, academics are not very good at hard-ball politics, so it will be a significant challenge to help our students use their citizen freedoms to advance the public health policy agenda.