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.

Social Determinants of Health and the Public Health Enterprise

Recently my local newspaper (Louisville Courier Journal, August 9) published a story about high school graduation rates in Kentucky and the local public school system. The news article included recent statistics on the graduation rate in the local school system as a whole, as well as a Table showing the graduation rates of freshmen students in the individual high schools.  In the system as a whole, about 1/3 of freshmen don't graduate. The other very dismaying data in the article is the disparity in graduation rates between the school with the highest rate (Manual High School, 92%) and the school with the lowest rate (Iroquois High School, 40%). The article did not give details about the analysis methodology, so the possibility is that some of the students included in the non-graduation group later finish school in some other way.  Nevertheless, it is disturbing that so many young people fail.  Such failure to complete a high school education has a huge impact on youth for the rest of their lives, including the expectation of poor health status compared to their peers who have more success and achievement in school.

Not being a K12 educator, I'm sure there are some things about this problem that I don't understand.  Failure to graduate is a function of student effort and motivation, parental support, instructional practices and standards, curricular options (e.g. practical career training), student suspension rates, special education services, second language programs, school leadership, and many other factors.  The problem is not simple, which is why drop out rates do not change easily.

The reason I'm writing about this is not to shed light on how to solve the drop out problem, but to point out the glaring contrast between this huge social problem that has a significant impact on the public's health, and the fact that almost no role is being played by the public health enterprise.  Poor educational achievement is what we refer to as a "social determinant of health."  Students  who do not finish high school live, as a group, seven years shorter lives(Washington Post, March 11, 2008)  than others.  Along the way, they are likely to have more sickness and sick days and a poorer health-related quality of life.  There are not many threats to health that take a seven year toll, making high school drop out a giant threat to health.

And so we return to the public health enterprise.  How should we address education as a basic factor to promote health status?Indirectly we contribute to student success in school, but measures to promote child and adolescent health, such as with immunizations and health screening.  We are very comfortable with designing interventions with outcomes stated in terms of health status.  For example, to decrease the rate of hospital admission among children with asthma.  However, what if we made school success and high school graduation the outcome measure?  What then would be the role of the public health enterprise, and how would we proceed.

Rectifying the startling results of health inequity, and addressing the social determinants of health will require revolutionary change in the ways we deal with public health problems.  It will be an uphill battle, given the current social resistance to brave new enterprises undertaken by we the people in the form of government initiatives.

Food Guides and Food Fights

Sometime during my childhood the U.S. Department of Agriculture developed and disseminated the Basic Four Food Groups guide to healthy diets.  The focus of this educational device was on assuring the ingestion of recommended nutrients.  Through the lens of history over the decades that have passed since then, the Basic Four seem like shoddy guidelines, riddled with Big Farming and Big Food special interests.  However, when the Basic Four were born, they were quite mainstream, and were considered a serious effort to enhance the dietary intake of Americans. At that time there was broad concern that many individuals and groups were not getting all the vitamins and minerals at the recommended levels.  Later on while the Basic Four were still in place, I was a public health student, and took a nutrition course, in which we learned about diet-related maladies such as scurvy, pellagra, rickets, and kwashiorkor.  We were primarily interested in deficiency, with very little attention given to obesity. 

Aside from the health science merits of the Basic Four Food Groups, it largely failed as a didactic device.  It became the poster child for irrelevant health promotion messages, and was usually discarded if not totally forgotten after middle school health class.  Nevertheless, at the beginning of the establishment of the Basic Four concept, the obesity epidemic we see now had not started, and even the diet-related risk factors linked to heart disease were yet understood.

In the early 19902, the USDA replaced the Basic Four with the Food Pyramid. It was a step forward in including broader health advice, such as "Use fats, oils and sweets sparingly,"  but it still was putting too much emphasis on dairy products and meat sources of protein.  It was not hard to see the influence of food and farming lobbyists at work, but the Food Pyramid was small, incremental progress toward addressing

chronic diseases related to diet, not just the deficiency diseases so common in earlier decades.

The Food Pyramid was recently replaced by a new plan called "MyPlate."  This has been given a lot of energy by Michelle Obama, who has made a focus of her time as First Lady to try to promote better eating and more exercise, as a way to decrease the child and adult obesity epidemic.

My plate represents another increment of progress, with the guideline that half of one's diet should be fruits and vegetables.  No longer is a preference shown for meat protein.  Not shown in the diagram, but in the narrative accompanying the illustration is the encouragement to preferentially select whole grain foods rather than refined.  On the other hand, dairy is still featured, with the stipulation that people should seek low fat and fat free options.  Unfortunately, there are millions of children and adults who are lactose intolerant, so this plan seems to leave them out in this regard.  There is no question that MyPlate could be better in some ways, but it is light years ahead of the Basic Four. 

It is created in the kitchen of national politics.  Given the pressures brought to bear on the White House and the federal government, MyPlate represents a very satisfying achievement in health policy advocacy.

Very recently, the Harvard School of Public Health has release its own rewrite of all these food plans.  The subtext is one of impatience with the political climate that has been imposed on evidence-based health practice.  This plan is called Healthy Eating Plate.  This dietary guideline is absolutely on target with the best evidence of healthy nutrition, suitable for all.  However, the implied criticism of MyPlate is a little unfair, since Harvard does not have to respond to all American stakeholders, just the scholars and

scientists.  The other problem with Healthy Eating Plate is its complexity.  While MyPlate is lacking in a few areas with respect to health guidance, it is a plan that is quite easy to explain to the lay public.  Healthy Eating Plate is more correct, more complete, but also presents a great challenge for disseminating to average Americans. 

If you are reading this you probably have more than a passing interest in health promotion.  What do you think are the challenges of driving the widespread adoption of guidelines as detailed as Healthy Eating Plate?