A brilliant thought that just occurred to me ... a note on culture

As a public health professional, I have been indoctrinated to continually consider culture and heritage as a part of interventions. We should, our professors say, carefully examine the normative values immanent in our target populations. We should analyze and plan and really, really think about not only what we say, but how we say it, and how we act when we do so. It's all about sensitivity.

I was thinking the other day, then, about the classroom environment and different teaching styles, and how professors should really be applying these same principles of cultural sensitivity to their students. We are, as master's students, existing in our own culture. We have specific norms and values, specialized language that describes our experiences, and certain socioeconomic concerns (i.e., we're generally poorer than poor). We have arguably created our own subset of society here in our public health school.

Why do I get the impression, though, that some ostensibly enlightened educators are contradicting their own teaching by refusing to understand students' viewpoints? I wouldn't necessarily call it hypocrisy, but I just don't understand how students at SRPH don't constitute a population that deserves consideration on par with needy community members. We're a group of people with specialized interests, and we ought to receive "interventions" (in this case, education) that has the same quality of the interventions we are designing in our courses. We don't berate or belittle people for doing things "wrong" in a health setting; why would we do this to students, who occupy an analogous social realm?

I'm going to bust out an old cliche: Practice what you preach! That's an imperative that is imposed on all of us that are in the health and wellness industries. Like it or not, people are unlikely to trust a nutritionist who only eats cupcakes, a doctor who smokes, or a public health professor who doesn't attempt to understand students' very legitimate cultural norms.

This is what we are called to do, thinking outside of the box. Cultural sensitivity isn't only good for understanding life in the colonias or in other countries, it's important right here in your own backyard. Learn how to apply it in your immediate surroundings, and you're certain to succeed when the tough situations arise.

I've come to the conclusion that being proficient at public health is really just being proficient at life. Here are the basic tenets of our profession, as I interpret them:

• Ask people what they want and need,
• Be nice,
• Try to understand people that are different from you,
• Admit that you don't know everything,
• Admit that you sometimes break things,
• Don't lie,
• Don't waste money or resources,
• Make sure what you're doing is working,
• Don't hurt anyone,
• One size does not fit all.

Were I a public health professor, I would give my students this list and then turn them loose to study whatever health topic they found interesting. I would give them the freedom to intuitively create interventions and then provide constructive feedback. This field isn't about following a formula to achieve a prescribed end. It's about engaging people and showing them that they can change their own health status and maybe even that of their community. It's about coming up with effective, exciting, and innovative ways to get things done.

It'd be great if that started at the institutional level, but I'm running out of faith that academicians can deliver what people really need. If they can't even get it right in the classroom, how can they get it right in the real world? Tough questions.

The great academic contradiction: Politics make an appearance

As the president of our public health school's student council, I am both responsible for the welfare of the student body and accountable to our faculty. That's fair. But I am experiencing a significant crisis of faith because of the contradiction between what our professors tell us and what they actually expect us to do.

At my new student orientation, I was told about the importance of "getting involved" in my community; how, as a public health professional, my unwillingness to assist others would portend career failure. I was admonished for not immediately accepting leadership roles (although I've since assumed a great deal of responsibility here at SRPH). Further, our teachers consistently tell us to improve our community awareness, involvement, and interaction to ensure future success in our career fields.

Yet, it seems that when we attempt to take these ideas for a test drive at our own school, politics get in the way. Professors think your strategic marketing plan steps on their toes. They dislike your initiatives that are aimed at breaking down the "silos" that inhibit public health from making a real difference in many community settings. They balk at your initiative, optimism, and enthusiasm. I resent this a little.

This prevailing attitude only reveals the true advocates in our midst. Despite the dissident population, I have received support from a few dedicated faculty who encourage innovative solutions to public health problems. They recognize the potential that our generation has to effect change in our world, in spite of our tech-based upbringing. I am thankful for these people.

I guess the point of this post is that I'm consistently shocked by the negativity leaders display when you do what they tell you to do. My professors want to break down barriers between departments and disciplines? When we start doing this in our student council, let us do it! We are an interdisciplinary group, and by golly, we ought to acknowledge that fact.

The imperative for change thus falls on those stalwart supporters and energetic motivators who truly want to change the face of health in our nation and world. Sure, we give lip service to innovative solutions to public health problems, but most of us in the academic establishment seem to want to spend time in our happy little laboratories drawing models and filling in charts, pondering our navels instead of actually making a difference. It seems like we're just spinning our wheels in so many ways because of political considerations.

It's going to be like this in the real world, I know, so it's almost better that we're facing it now, in school, but for a starry-eyed idealist like myself, this whole process takes a little bit of the luster out of the profession.

Tuberculosis: It's all the fashion rage!

In last night's epidemiology class, my professor said something very insightful. We were talking about Victorian era public health, and somehow beauty standards were tossed into the equation. To paraphrase, he said:

The Victorian beauty ideal, at least for Caucasian women, was thin, frail, and waif-like. This, coincidentally, described a woman with tuberculosis.

That comment sparked a massive internal dialogue for me. So much that I could barely even focus during the rest of class. It was as though all of the ridiculous beauty standards to which women are upheld were suddenly flashing before my eyes, bolstered by historical precedent. Painful beauty routines for women are ubiquitous throughout cultures and geographical distributions. These aesthetic requirements even cause us to compromise our health.

Women's pursuit of beauty could very well kill them.

The Victorians thought you looked great if you had a deadly respiratory disease. Really. That's what they considered "hot." Is it so different in other countries? Not really. The implications of this statement, aside from the obvious eating disorder concerns (which may or may not be related to "beauty," but that's another topic), are massive!

I thought about

• Foot binding: crippled women
• Genital mutilation: dehumanizes women
• Permanent makeup: tattooing our faces! ouch!
• High heels: cripple women still
• Corsets: caused us to faint and put unnecessary pressure on our internal organs
• Waxing: self-explanatory pain. Also, makes us look like pre-pubescent girls if performed on certain body parts (which is creepy!)
• Hair products: exposure to potentially carcinogenic chemicals
• Parasites: to help us lose weight (yep, seriously)
• Lysol: to make our vagina smell fresh (also, yes, seriously)

This list doesn't even include the weird devices we use:

Anyway, maybe you all already knew everything I'm writing about, but the enormity of this topic really just sank in last night. It was like getting hit with a brick wall.

I think those of us in the public health professions have a responsibility to promote healthy beauty ideals, not those that harm us. In light of the recent obesity freak-out, I think it's critical for us to maintain a skeptical perspective about what's "good for us." I'd rather be killed by Teh Dethfatz than an intestinal tapeworm designed to keep me slim and trim. Just saying.

Risky business! Are you a sensation seeker?

Much of my research and professional experience focuses upon ergonomics, workplace hazards, and traffic safety. A major component of improving public health in these realms is compliance. Well, really, that's a problem with any public health program: How do we get people to do what we want them to do? That IS the basis of our course of study, at least in the social and behavioral realm.

We generally try to avoid blaming the individual person for his or her health decisions, rather focusing on the system that fosters such choices. Systemic changes, we think, enable people to naturally make the "right" choice for themselves, or at least a well-informed "wrong" choice.

Some people, though (myself included), are just high-risk folks. I always theorize that certain professions attract social deviants:

• If police officers weren't cops, they'd be criminals.
• If chemists weren't working on pharmaceuticals, they would be making meth.
• If ski patrol wasn't bombing for avalanches, they'd be arsonists.
• If safety professionals weren't teaching safety, they'd be dead.

Here's a cool link to a self-assessment tool for determining your sensation-seeking rating (goes from "titmouse" to "adrenaline junkie").  I, consequently, fall into the highest category, which makes sense.

I feel as though I am a great public health/safety professional because I'm the most likely person to do stupid stuff. I've skied helmetless in the backcountry, ridden motorcycles at 70mph on the freeway while the driver was drunk, and raced at speeds up to 120mph on San Antonio's roads. I've worked in chemical demil facilities that had gallons of VX nerve agent in the lab hood. I have handled dangerous chemicals without gloves or protective eyewear, and I did the same with urine on more than one occasion. I SCUBA dive, ride in small planes, get on every roller coaster I see ... and yes, I've had unprotected sex. I still run with scissors (don't tell anyone). I've done it all wrong.

I have had (in the past) almost no regard for my own personal safety. Frankly, I hit age 25 and was shocked to still be around. I was lucky. Other people aren't. This is why I appreciate the importance of safety initiatives and messages; people really do get hurt. I just lived long enough to tell my story.

In other words, I am my own target audience. If you can make me change a health behavior, you can probably convince anyone.

This is a great asset, because I'm able to critically evaluate programs' ability to succeed in real life. Is the program inconvenient? Culturally insensitive? Gender-biased? Yep, I'll find any excuse to not be healthy. Which is why I'm perfect for this discipline. If I can save people from one of the horrific deaths that I narrowly avoided, then I must be fulfilling my greater destiny. And I suspect that many public health professionals can say the same.

I hope to see some comments telling me about YOUR sensation-seeking scores! It's really a fun test.

CDC's Health Out Loud ... Entertainment and public health belong together

Here at the School of Rural Public Health, we are often encouraged to think about innovative ways of including public health messages in general media. Specifically at our school, because of our proximity to the Mexican border, we often discuss telenovelas, popular soap operas that have previously been used to disseminate information to disadvantaged Hispanic populations. These are very well-received and prompt a significant change (in some cases), when paired with other public health efforts.

I be you didn't know that the exact same thing happens on American television! Check out the CDC's blog today about a new episode of "Army Wives" that addresses the topic of Traumatic Brain Injury (TBI). Link here.

Here's also a link to the actual video clip in which TBI is discussed.


Although this approach is nothing new (I've read documents dating back to the 70's that address public health in the media), it's interesting to see how issues have changed, and how they may have remained the same.

One of the biggest issues we face as public health practitioners is the continued portrayal of illness as:

• Quickly cured
• Affecting only white, middle-class patients
• Exotic and difficult to define (i.e., not diabetes ... instead, amnesia!)

This, frankly, is not what illness is in this nation. We are a group of people with chronic conditions that are fairly common. We have high blood pressure, diabetes, arthritis, heart disease ... none of which are particularly glamorous. Trauma makes for better TV, but it doesn't help Americans understand the health care system.

I have to admit that I am particularly fond of the TLC show that shows true stories from the ER; although some of the ailments are sensationalized, we get a feeling for what might actually happen in an Emergency Department, rather than what Hollywood would have us believe. Teens actually do come in after overdosing on drugs, for example, and car crashes are among the leading causes of preventable deaths for Americans in general. The TLC show portrays these events accurately, in my opinion.

In essence, I hope that we see more information dispersal like this clip from Army Wives. Although it wasn't on a major network, I think it portrayed a fairly realistic situation. We have an obligation, as public health professionals, to promote these surreptitious but effective mechanisms for social change.

In defense of innovation

I'm currently reading this excellent book by Gerald M. Weinberg called Becoming a Technical Leader: An organic problem-solving approach. This, along with some recent class experiences, has prompted me to start thinking about the real place that innovation has in the public health care realm.

Public health, unlike computer science and other technical disciplines, is unlikely to be revolutionized by that next great idea; a single spark is unlikely to ignite a flame. That attribute, however, doesn't prevent public health from the need for great and innovative ideas. Ideas that were not forged in a sterile academic test environment ... no, those ideas are inadequate. What we need in this field, what our populace deserves, is a thinking and creative workforce that creates new approaches to old problems.

I was troubled today by a response I received from a teacher during class. I quoted the 1998 book Public Health and Marketing, which asserts that public health practitioners need to adopt strategies and mindsets that exist in the marketing realm. Specifically, we are encouraged to realize that corporate marketing professionals only expect a 2-3% per annum change in purchasing behavior (note the "per annum"). In other words, public health professionals need to set more realistic expectations for mass behavior change. This seems reasonable to me, as someone who does a lot of independent research, because I have yet to see sufficient evidence that behavior change can be achieved through educational efforts.

I was thoroughly trounced, albeit politely, by my professor, who essentially laughed at me, telling me that any proposal that promised a 2-3% change per annum would be swiftly rejected for its inefficiency. Let me bring up the following points, though. For example, in a 5-year program, assuming a 3% change annually, one could effectively change at least 15% of the target market. Perhaps a 2-3% change is warranted because of the characteristics of the health problem; if we're changing 2-3% of the rates of homicide in the U.S., for example, we might have an argument for the program if it's low-cost and efficient. Furthermore, those affected by the change may have the ability to influence their community, effectively changing social norms.

There must be something wrong with me because I have the continuous faith that professors, fellow students, and the public as a whole are as optimistic and revolutionary as I choose to be. Yes, I do my public health research. I read books upon books that have nothing to do with class, but everything to do with actual implementation of public health principles.

Take, for example, the remarkable book Theory in Health Promotion Research and Practice: Thinking outside the box, by Texas A&M's own Patricia Goodson. I won't go into detail about the book (since I'm honestly not done reading it), but the title alone should make us stop and question our motives in this field. Thinking outside the box. Theory does have its applicability, and evidence-based public health practice is important, but our field must also be receptive to the radical and weird ideas that just might change the world.

Why are we stumbling around within our profession when so many questions have been answered by research in other disciplines? We have a problem with our marketing strategy ... why don't we look at marketing research to fix the problem? There's a reason that the big corporations are dwarfing our public health efforts ... they have the resources to hire the best and the smartest campaign development staff. Our field seems to be sinking in stagnation and self-congratulatory angst. I'm kind of not impressed.

I am compelled by Weinberg's leadership model, which calls upon technical leaders to motivate, organize, and innovate. The overall theme of the book calls upon those who have been innovators in the past to stimulate new ideas by creating motivation and organization that supports new ideas.

As a leader in this field (which I hope to be one day), I can only say that I would be remiss if I didn't entertain some wacky approaches to public health; after all, we really have no idea what works in this field, so how can we trust the evidence we have? Goodson says that it's rather insane to think that we can imagine ourselves capable of predicting others' behavior. "Well, I raised his self-efficacy, so there must have been an improvement," we say, without understanding what those catch phrases really mean.

The point of this post, I suppose, is to request that public health academicians step down off their beautiful high pedestals and come join the rest of us in the real world, where things are messy and difficult to define. Allow us to think radically. Allow us to feel empowered to go out into the world and make changes! I don't want to work within the crappy existing framework that public health requires, and by golly, I don't have to.

I want to think critically about problems using a variety of perspectives, and I intend to apply theory from *gasp* other disciplines such as engineering, economics, manufacturing technology, and management. Get it together, folks. Public health is the ultimate conglomeration, the meeting place for all courses of study, and all should be recognized as valid. Who cares if it's theoretically supported if it works?!

Maybe I'm just a starry-eyed optimist, but so are others who really make a difference.

Here's your infected speculum ... yum.

So this is pretty much the most horrifying public health lapse that I've heard of recently in our nation ... and guess what? It happened right here in Texas.

Apparently the Parkland Memorial Hospital incorrectly sterilized not just a few, but at least 70 speculums.

A March 2010 letter to clinic patients said, "We would like to let you know that you may have been exposed to a speculum"—a vaginal examination instrument—"that may not have been properly sterilized." Although the infection risk was very low, the letter added, "we would like to evaluate you in our OB/Gyn Intermediate Care Center as soon as possible to offer you preventive medications."

Two days later, another letter told clinic patients they needed to also alert them to the possibility of infecting a sexual partner. "We would recommend that you abstain from sexual intercourse or use condoms until notified of negative results after your six month follow up," the letter said.

A third letter soon went out to a different group of women that warned of another possible failure to sterilize instruments. This time the problem had occurred in Parkland’s labor and delivery department, one of the nation’s busiest.

Yep, so this information is just now coming to light because of freedom of information inquiries. Can you imagine being one of these women? Getting letters like this out of the blue, telling you that some rotten and unclean speculum has been used during your exam? I just threw up a little bit.

Hospitals are supposed to be bastions of professionalism and cleanliness, and yet we hear about events like this all the time. Infections that kill patients, botched operations, ineffective medication management. Mistakes like these, if made in other industries, wouldn't be such a big deal; the auditor catches the misplaced decimal point, the copy editor corrects the grammar error, the janitor cleans up your spill. But in the medical community, we can't just write off errors such as these to human nature.

We have to wonder, also, whether this hospital possesses the correct financial and administrative resources to serve the needs of its surrounding community. I'm not familiar with the demographics of the nearby region, but the hospital may primarily serve underprivileged individuals; if this is the case, perhaps more government funding is necessary to ensure the availability of equipment and staff to guarantee patient safety.

I think many hospitals lack the financial or managerial resources to institute proper systematic controls that would prevent errors such as these. Why would a system allow technicians to retrieve dirty speculums? Shouldn't there be a mechanical safeguard to stop such an event? Further, what kind of managerial pressures are being exerted on technicians to sterilize quickly without regard to process quality?

In short, the hospital has pledged to fix this problem through increased monitoring, but I don't think that's the problem. An environment that encourages productivity over safety, regardless of the product, is unsafe for everyone. This is true of manufacturing environments, hospitals, and even office workplaces.

I think a careful analysis of the organization's culture will reveal far greater problems than dirty speculums. Perhaps the hospital, under threat of lost Medicaid and Medicare funding, will learn to clean up its act.

Let's encourage little girls to diet! Brilliant!

Although I pilfer most of my links from Jezebel, and I'm trying very hard to stop doing this, I found this GEM through my daily reading of that site.

The book, which ostensibly encourages youngsters to eat appropriately and exercise, is ... well ... appalling.

I remember when I was in my early teens ... yeah, that's right, that's when my eating disorder started. Let's remember that environmental factors are not the only components to eating disorder development, but I can guarantee you that books like this would have just made things worse for me (and the other, what, 1/3 of girls who have disordered eating patterns). I had problems just going to the doctor and finding out I was "overweight," even though I played 3 sports.

Furthermore, let's remember that a large percentage of our nation's young women would rather be hit by a truck than be fat. Information here.

So, what about those girls who play sports, like Maggie did (and I did), and still don't lose weight? This book implies that it's their fault ... although they might just be sturdy little soccer players like me! What about those of us who remain physically fit, yet straddle the clinical definitions of overweight/obese?

I just can't see this book as anything but a mortifying and appalling excuse for a "positive health message." Read a health marketing book, lady. Guilt doesn't work to change behavior, and you're expecting kids to have the cognition to understand the concepts in this book without adopting harmful strategies. #facepalm

If people like this keep dominating the health communications marketplace, we're all doomed.

National Health Center Week!

How do I keep missing these awesome commemorations?

It's apparently National Health Center Week, an effort supported by Aetna, Sharing the Care, and other corporate and government-based entities.

Health centers are critical to the public health efforts we work for every day. Why? Because they are often located in impoverished, disparaged neighborhoods with few other resources. They are the tie we have, as public health professionals in our towers on high, to the actual populations who need our help. They are the front line defenders against maladies associated with homelessness, poverty, and inaccessible medical care.

National health centers also provide care to immigrant and nomadic workers, populations that are also medically vulnerable.

Now, before I start hearing all of the "they're taking our jobs!" arguments and other such nonsense, I'd like to point out that one of the basic tenets of public health is as follows:

A healthy nation is a happy, productive nation.

If we support the health of everyone who's in this nation, we are not only being decent human beings, but furthering the interests of all Americans (and people who just happen to be here). Now I'm the farthest thing from a "bleeding-heart liberal," but that's an ethical foundation I can stand upon. Sick people, logically, cost us more than healthy people in most cases, right? So, duh, let's keep everyone well.

We might argue that immigrants and others who use the national health center system are draining our resources. Oh, contraire, though, my friends. If they're using the health center system, then they likely are visiting the appropriate medical facility for their needs, rather than congesting local emergency rooms with minor ailments. This is a good thing.

So, enough with the minor tangent.

Did you know that we have a community health center right here in Brazos County? Yep, it's there! It provides low-cost medical care to lower-income individuals in our area (*cough, cough, GRADUATE STUDENTS). I've been to the health department to receive low-cost immunizations that even the campus health center couldn't provide. Gardasil for $30 instead of $150? Yes, please!

Anyway, let's take some time this week to consider the contributions that these little-known facilities make to the overall health in our nation. They don't have glamorous jobs, and they sure aren't famous people, but they are out there making a difference, and I am so grateful for their presence.

Public health theory links ... helpful for social and behavioral students (and everyone else!)

I'm a big advocate of using theory to create public health programs, instead of just trusting your "gut." Too many public health practitioners, who are poorly trained in theory and evidence-based approaches, put together programs like this: FocusDriven that are largely designed to appeal to our emotions and fear of physical injury. Although I suppose these worked at one time, campaigns such as these slip out of our conciousness the minute we navigate to a different page.

With that in mind, I've found some really awesome articles that summarize public health theories relating to behavior change, and I'm going to share them here! Get stoked!

• This article from the National Institutes of Health relates specifically to cancer, but the information can be generalized to most public health practice. This is probably the most practically applicable document I've seen that relates to public health theory.
• Here is a file that summarizes public health theory nicely, including some that you usually don't see, such as Protection Motivation Theory and the Elaboration Likelihood Model.
• Finally, it's important to recognize that different populations require different theoretical models to inspire interventions. Children are a particularly relevant group because their cognitive abilities differ greatly from those of adults. This article explains a child-specific model that can be used to spark behavior change.

Again, it's important that public health professionals adhere to existing scientific knowledge in crafting campaigns and interventions. Otherwise, taxpayer money and funds from private enterprise are essentially discarded as they are applied to feel-good efforts that really don't fix anything.

I'm continually shocked at the inability of our health community to lay proper foundations for research and intervention. Perhaps this is because many of us in this field are poorly educated about public health, considering the current clinical focus of medical technology today. It's clear that a paradigm shift must occur that stresses true evidence basis instead of self-serving, happiness-inducing, ineffective programming.

This means that we, as public health professionals, must acquire enough knowledge to recognize when something is a bunch of horse hockey. Learn your statistical measures. Understand what total crap looks like. Sources will tell you that D.A.R.E. is an effective program, for example ... but if you actually READ the studies, the evidence for this suddenly vanishes.

Think critically, people.

Man denied breast cancer treatment ... because he's a man. Really?

Check out the link here about a man who was denied Medicaid coverage for his breast cancer treatment because he is not a female.

Interestingly, the article points out that the man applied for aid through a breast cancer and cervical screening program that only serves women; that is, the defined mission of the organization is to assist WOMEN with these problems, not men. I find it difficult to swallow that this organization is to blame for his lack of coverage. This is also mentioned in the Jezebel article, so kudos to them.

For example, the Juvenile Diabetes Research Foundation primarily deals with Type 1, or early onset, diabetes in child populations. Suppose the JDRF provided charitable support for individuals with this condition. Now, imagine that someone with Type 2 diabetes, or gestational diabetes, applies for financial assistance from JDRF. The organization is dedicated to a different population, however, and so denies the request. There's really no difference between that and the breast cancer situation described above.

Organizations exist to serve specific populations, and that's OK. The flaw isn't with the breast and cervical cancer screening programs, as the Jezebel article points out. Rather, our system is failing because of its inability to provide comprehensive care to everyone. If the American healthcare system was fortified with more safety nets for populations with health disparities, impoverished men with breast cancer would be less likely to fall through the cracks.

We need to allow organizations to focus on their self-defined mission rather than attempting to dictate morality to them; a women's group doesn't have to provide healthcare to men (just like a fathers' support group doesn't have to allow mothers to join). I'm glad that the editorial attacks the general healthcare structure instead of vilifying the women's health organization.

If those groups weren't allowed to set boundaries, I think it would be a slippery slope into chaotic public health practice. I can see the nature of these conversations:
"You have an AIDS foundation? Give us money to help cancer patients!"
"Um ... no?"

It's not that we shouldn't care about groups with different health problems. Rather, we need to acknowledge and realistically assess the independent ability of non-profit groups to support specific populations, strengthening our overall infrastructure to support these efforts.

Borderline personality disorder ... mental health in sports news? Yes, we're excited!

So, I'm hanging out with my S.O. yesterday, and I see him reading some sports news. Meh, no big deal, I think ... I'm not usually excited by A&M's football prospects or which hitter has the best RBI. But then, out of the blue ... a public health article sprouts up in the sporting world that has nothing to do with performance-enhancing drugs or nasty ACL injuries. Yep, it made for a great Sunday.

Here's the scoop: Miami Dolphins wide receiver Brandon Marshall went public with his diagnosis of Borderline Personality Disorder (article here). For those of you who aren't mental health experts, Borderline Personality Disorder (BPD) is characterized by the following:

1) frantic efforts to avoid real or imagined abandonment

2) a pattern of unstable & intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

3) identity disturbance: markedly and persistent unstable self-image or sense of self

4) impulsivity in at least two areas that are potentially self-damaging (e.g. spending, sex, substance abuse, reckless driving, binge eating)

5) recurrent suicidal behavior, gestures or threats, or self-mutilating behavior

6) affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)

7) chronic feelings of emptiness

8) inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

9) transient, stress related paranoia or severe dissociative symptoms

(More information from a DSM summary here)

The most important part of this whole situation is that Marshall is making his struggles with BPD public. BPD may not be on many people's radars as far as important mental health issues go, but that doesn't matter. What excites me abot this article is that a ridiculously successful (Pro Bowl anyone?) professional athlete is unabashedly admitting to a relatively severe mental illness.

The message? It can happen to anyone.

As more and more people come forward to share their struggles with mental illness, the stigma and hype surrounding such conditions will begin to wane. This is why I am always so forward about my struggles with depression and an eating disorder; by making these things a secret, I would be playing into the social expectations of guilt and embarrassment about my mental health. I'm so happy to see high-profile folks like this coming forward to help fight for the cause.

I do feel terribly sorry for Marshall; even with practically unlimited resources, he's continued to struggle with this difficult condition. This article, however, highlights another important point about mental illness that we can scarcely afford to forget:

A man with nearly unlimited resources at his disposal still struggled immensely with mental illness.

Not only do mental illnesses not discriminate ... they also require specific, individualized treatment plans and a lot of dedication to overcome.

This is particularly salient in light of the recent health care reforms, which have re-opened the debate about insurers' responsibility to those of us who suffer from mental illness. If recovery is even difficult for a man with access to so much care, what can we expect for those with health disparities? The dearth of mental health services for all Americans is inexcusable; although the physical maladies may present themselves with more clarity, mental illnesses are also fatal diseases. We can't ignore the implications that mental illnesses have for overall improvement of care.

So, a big THANK YOU to Brandon Marshall for "coming out" as someone with a mental illness! Here's to shattering more norms!

Suicide among middle-aged women

A newly released study from the Substance Abuse and Mental Health Services Administration (SAMHSA) shows that middle-aged women's suicide attempts are at what might be an all-time high. (article here).

The majority of these attempts are drug-based, which coincides with most suicide research about gender differences in preferred method of personal dispatch; men are more likely to use firearms, while women are more likely to attempt to kill themselves with drugs or other toxic substances. Not surprisingly, men are generally far more successful, but the incidence of female suicide attempts is significantly higher. I'm not citing this information because I've read so much about suicide and mental health during the past 10 years that I can't even remember where I found all of these facts ... but I'm certain they're out there somewhere. Happy hunting, blog readers.

Anyway, this blog isn't about pointing you to interesting documents and factoids about health (all the time), so today we're going to launch into a discussion about mental health services in this nation and how women's health is grossly neglected. And .... go.

So, middle-aged women make up one of the fastest-growing demographics for newly diagnosed eating disorders. Middle-aged women are also apparently attempting to kill themselves more often. What gives? The linked article talks about hormone problems, "empty nest" syndrome, and other biological/psychological motivators, all of which seem perfectly legitimate. Have we stopped to think, though, that this generation of women might have been left behind by the healthcare system? That we have been carefully ignoring their needs for years?

My mother, for example, has had to practically pull out her doctors' teeth to get them to test her for heart conditions (they run in the family) and hormone problems (yep, I have them, too). These are relatively straightfoward conditions; imagine if my mom was like the woman in the linked article. Schizophrenia? Yep, good luck receiving appropriate treatment for a condition like that.

I imagine that if it's difficult for these women to receive adequate physical care, mental health care must be lacking.

This article is simply another supporting document for the degrading quality of healthcare in our nation (in my opinion). Using carefully collected anectdata (joke), I have found that many of my friends and family members have been ignored, if not flat-out mistreated, by medical professionals at university health centers and specialists' offices alike. Our healthcare system is sick and unable to accommodate physical and mental illness, despite increasing technological power.

This article also states that ONE IN FOUR Americans has a treatable mental illness. That's right. 25% of America is mentally ill (count me in the ranks!). Yet, mental illness is still so heavily stigmatized, and insurance companies are ridiculously hesitant to provide even a small bit of coverage for problems such as eating disorders and depression.

The implications of our social condition contained within this article are just too great to ponder. Gender politics, marginalization of the mentally ill, the cultural traditions of the Baby Boomers .... #head_explosion

I hope you enjoy thinking about these problems, as well. Get back to me when you've come up with a solution.

It's Junk Food Day ... are you getting yours?

It's National Junk Food Day! I found this out as I was browsing the news sites this morning, here and here.

Now, as a public health professional, I know you're all going to expect me to sit up on my high horse and preach "eat your veg!" and "leave junk food alone!"

But I'm not going to do that. In fact, I find that perspective overly simplistic and frankly more than a little upsetting.

Junk food has a place in your diet. It has a place in my diet. It has a place in everyone's diet!!! *sound of shocked public health professionals everywhere* Yes! Really! It does!

If anyone has ever heard of the Health At Every Size movement (HAES), or Intuitive Eating, you would know that by perpetuating the idea of the "food police" we are just harming our natural drive to eat what our body needs. That's right, we should trust our bodies to tell us what we want to eat. Sometimes I eat chocolate cake for dinner for a week straight. Yes, I admit it. I'm not the strictist dieter, and I don't beat myself up when I want chocolate cake. I don't eat it every day, but there are times in life when you want a sweet or salty treat! It's OK!

After I've eaten all that chocolate cake, though, it's generally not surprising that I reach for oranges, quinoa, spinach, and other delicious alternatives for a long time. When I was going through eating disorder treatment, I ate chicken wings and pie for about 3 weeks straight, because I was finally "allowed" to do so. I haven't had them since. I don't feel guilty about either choice.

I eat what I want, as much as I want, when I want to. Really. Sometimes it's a lot, sometimes it's a little, sometimes it's in the middle. And my life's better for it.

Point being, if you deny yourself junk food when you really want it, I think you're more likely to binge on it later. The whole point of public health is to create normal eating patterns and provide adequate access to reasonable food options ... for everyone. Now, someone tell me that junk food is not part of a normal American diet ...

Yep, didn't think so.

Let's acknowledge junk food, celebrate its importance in satisfying our sweet tooth, and stop vilifying everyone who cracks open a package of Oreos every once in a while. Isn't our overall health a little more important than maintaining a perfect weight all the time?

I'm overweight. I eat junk food. I'm a vegetarian. I'm also pretty darn healthy (mentally and physically). So Happy Junk Food Day! Throw back some Lay's, Twix, Skittles, SnoCaps, Milk Duds ... you get the picture.

You're not a bad person for wanting some junk food. Don't beat yourself up endlessly about it.

For more, see what The Fat Nutritionist has to say.

Should obese children be removed from their homes?

The most recent post at our friend Dances With Fat deals with a controversial JAMA article that asserts that grossly obese youngsters should be taken away from their parents. Ragen pretty much nailed the main points that I wanted to discuss, and she's kind of an expert on this one, so I'm ceding to her opinion.

One thing I would like to add, however, is my never-ending argument that obesity is sometimes a symptom of a more serious illness; individual with certain mental disabilities, for example, overeat because of malfunctions with their brain structure. Similarly, hormone conditions, endocrine disorders, brain tumors, and other conditions all pose as simply "eat less, exercise more," and they are commonly dismissed (in my opinion) by the medical establishment.

It's easy for us to put the onus of this problem on the parents of obese children instead of accepting that, as a society, we may all be the ones to blame. In fact, children's food choices are not totally dependent upon their parents, and studies have shown that more parental control over children's diet = higher likelihood of obesity. Here is an interesting study that discusses the complex nature of children's food intake and their relationships with their parents.

Ultimately, the question here is whether the community or the individual family unit is more responsible for children's welfare. Although it takes a village to raise a child, I wonder how much intervention our children should face from the government. Also, the costs associated with such an effort would be immense, and I find it hard to believe that health savings would outweigh the bureaucratic losses and legal implications involved with this action.

I see this study as a radical ploy to open discussion about this topic, instead of a realistic proposition for intervention. In that context, it is a useful, if culturally irrelevant, piece. Americans don't want the government in their refrigerator, and they frankly shouldn't.

In other words, just all public health problems, there is no easy fix for this quandary. Taking kids away from their parents for being fat is just an overly reactionary strategy with little basis in public health theory ... it's not an appropriate intervention. Behavior change is not fast or simple, and sometimes we need to allow our social programs time to work before we release such incindiary information into the public sphere.

MSN tells us valuable things about our mental health!

Actually, that's not sarcasm. Here's an interesting point that was made by recent research that's striving to clarify youngsters' depressive symptoms: Kids' mental health paradigm

The most interesting thing to me about this article, though was the headline. You would think that the depressive symptoms are prompted by some genetic component related to maternal heredity; rather, almost the entire article addresses implications for new measurement of depressive symptoms in children.

Isn't it interesting how the media is able to frame things differently by simply changing a headline? Those of us who aren't willing to click to the actual article would be poorly informed in an important public health matter because some lazy copy editor didn't bother to read the text. (This is coming from personal experience ... I was a copy editor many moons before, and I would have been heavily punished for something like this).

Anyway, what I'm trying to get at is this: We need to stop pinning kids' mental illness on their mothers, for genetic reasons or otherwise! I am so tired of mothers shouldering the blame for everything from anorexia to depression and bipolar disorder. The fact of the matter? Mental illness has behavioral and medical components, few of which can be attributed to (non-abusive) parents.

It's unfair for us, as health professionals, to buy into the baloney perpetuated in the media like this. A critical eye is a requirement in this business, and I would encourage all of us to dig deeper than just the headlines.

Did you know ... political groups try to frame public health issues FOR you?

I have been researching common advertising themes that are effective among younger populations, and I came upon this Web site today. The Center for Consumer Freedom is an industry-funded site that purports to tell "the truth" about obesity ...

- The government is controlling you by calling out food manufacturers about their shoddy labeling;

- The government is interfering in your basic rights to be an American;

- Obesity is not caused by fatty foods;

- Exercise will cure all obesity;

- Sugary sodas are good for you because they help the performance of elite athletes (seriously, this is their argument. See study here and "unbiased" interpretation here).

I must admit that their ad campaign is incredibly clever, appealing to basic American principles such as freedom of choice, independence, liberty, etc., etc. However, it's important to recognize that this is all a sham, at least from a public health perspective.

The food lobby is using the same arguments that the tobacco companies used in the past few decades: Our product isn't dangerous for you because we say it isn't! Your freedom to eat (smoke) is being infringed upon! NO MORE BIG GOVERNMENT!!! BLAHHH!!!!

Have you ever wondered why they're using these outdated and ridiculous arguments? Maybe it's because many food giants are actually owned by tobacco companies (as you might find in this awesome article about marketing food to children). For example, Philip Morris, under its alias Altria, owns both Nabisco and Kraft foods. Are we surprised that they're using the same detrimental marketing and social influence techniques to make sure their products remain on the market?

I'm all about supporting individuals' right to choose, but I'm also all about them receiving accurate information about what they're putting in their bodies. If I know that my food is chock full of chemicals, and I understand the ramifications of eating that food, then I assume responsibility for my consumption patterns. If, however, I am coerced into believing that the food I eat is NOT HARMFUL, how can I be expected to make reasonable decisions about my diet?

Again, I think Twinkies and Ding Dongs have their place (i.e., occasionally on my plate), but I understand the risk associated with those products. I wonder whether the rest of the nation really "gets" what's going on ... or whether they're being manipulated by the same crappy companies that used to market cigarettes to kids and the urban poor.

Also, let's not forget that industry-sponsored initiatives often prompt the "boomerang" effect, encouraging people to engage in the negative behavior instead of preventing illness. Ex: The tobacco industry's anti-smoking ads actually encouraged more kids to smoke (as we addressed in an an earlier post on this blog). Do you think McDonald's or Coke's fitness initiatives are really going to promote health? Or are they a surreptitious way to promote inactivity?

Looks like a job for The Public Health Models. We'll keep you updated on this topic.

Interpersonal communication with your doctor ... improvements on the way?

Today's New York Times featured a front-page article about a new interview process that is being used in medical schools throughout the nation, most notably the newest in Roanoake, VA:

Medical schools require people skills

The interview process involves an increased emphasis on patient-doctor interaction. This approach attempts to minimize the number of ranking medical professionals who inappropriately bully their staff or surpress patient interaction. Instead, a new focus is emerging that will ostensibly prevent patient injury by improving the population of doctors with developed communications skills.

In other words, your doctor won't be a jackass who orders nurses around and refuses to listen to your complaints.

This is a concept that I have been championing informally for the past several years after a series of difficult interactions with medical professionals. I understand that the technical side of medicine is important; after all, if you don't know what kind of medication to prescribe for a specific ailment, you're unlikely to be a good physician. On the other hand, though, I think it's important for doctors to realize that suffering from an illness is a very scary and emotional time for most people. Even a minor injury or condition can cause significant emotional stress because of the uncertainty and lack of control the patient experiences.

It is imperative that our modern medical establishment transition from the "doctor-on-high" perspective to a system that promotes team-based cures; that is, we should involve the patients in their own recovery instead of only dictating their courses of action. This is likely to encourage better compliance because the patients feel invested in their own health plan.

I think this new interviewing method is a fantastic concept. However, I wonder how many people will simply attempt to "study" their way around the interview by training on specific ethical questions instead of learning how to truly communicate. I believe that might be a significant problem, especially considering the characteristics of many students who are interested in applying to medical school. Potential physicians may see this test as simply another barrier to prepare for, instead of understanding the true value of communication in the healthcare setting.

I truly hope that this approach is a harbinger of a new direction for the healthcare establishment.

Did you know ...?

... that out of every 2,000 drunk drivers on the road at any time, only 1 will be arrested?

That translates to about a 1/300 chance for heavily policed area, and a 1/1,000 chance for areas with less enforcement.

Furthermore, most drunk drivers have driven drunk at least 30 times before they were caught (according to self reports).

In other words ... it's scary out there, and drunk driving is still a HUGE problem. I'm working on a review of effective media and interpersonal interventions to limit drunk driving, and it's hugely discouraging. I'm thinking that legislative and behavioral interventions are unlikely to seriously affect this problem; however, environmental interventions such as interlocks might be more effective.

(This is my theory, despite the fact that a drunk driver could just have their sober friend blow into the interlock to start the car).

In my opinion, the best decision would be to increase availability of taxis and public transportation to encourage safe journeys home at the end of the night. Either that, or encourage people to live closer to their favorite bars. That's exactly what I've done, along with many of my friends, and I'm rarely tempted to drive after imbibing.

Does anyone have thoughts on how to stem the tide of drunk driving accidents? Or are we all going to be perpetually at risk?

The four types of risk-based decision-makers

Traffic safety has long relied upon the theory of deterrence to maintain positive public health outcomes. That is, we have assumed the following:

(1) The human being is a rational actor,

(2) Rationality involves an end/means calculation,

(3) People (freely) choose all behavior, both conforming and deviant, based on their rational calculations,

(4) The central element of calculation involves a cost benefit analysis: Pleasure versus Pain,

(5) Choice, with all other conditions equal, will be directed towards the maximization of individual pleasure, (6) Choice can be controlled through the perception and understanding of the potential pain or punishment that will follow an act judged to be in violation of the social good, the social contract,

(7) The state is responsible for maintaining order and preserving the common good through a system of laws (this system is the embodiment of the social contract),

(8) The Swiftness, Severity, and Certainty of punishment are the key elements in understanding a law's ability to control human behavior.

(taken from Robert Keel's article here)

Examining these ideas, however, launches us into a whole mess of social issues, particularly those dealing with behavior. I don't believe that the deterrence theory actually describes individuals' likelihood of risky driving; people are not inherently rational, and so threat of punishment is not always the most effective way to initiate change.

Rather, I would argue that these guys have a much more compelling viewpoint concerning individual risk assessment and driving behavior. (Bear with me, I know it's an article about deranged world leaders, but it really does apply ...)

Lebow & Stein argue that four types of risk-based decision-makers exist:

-          Risk-prone gain maximizers: Likely to drive distracted because they gain something.

-          Risk-prone loss minimizers: Likely to drive distracted because they are afraid of losing something.

-          Risk-averse gain maximizers: Less likely to drive distracted because not doing so brings benefits.

-          Risk-averse loss minimizers: Less likely to drive distracted because they are afraid of losing something.

They also argue that the most dangerous among these are the risk-prone loss minimizers, because they have the proverbial something to lose.

I would contend that this is also the case. People don't want to put their cell phones down in the car because they're afraid of missing an important communique; an inflated sense of self-importance has encouraged us to imagine that the actions of the whole world hinge upon our ability to answer our phones. Imagine having that ability ripped from your grasp.

Just another theory in the toolbox of effective public health promotion .... Today's lesson? Identify and target your audience.