Cultural Comic Books for Educating Asian Americans about Hepatitis B

By Viet Le
Posted: May 24, 2013

There’s the story of a young Chinese American couple planning on getting married, but on the day of the proposal the bride-to-be confesses to her fiance that she has hepatitis B. Then there’s the one about a Korean immigrant family in which the father, who prefers traditional Asian medicine over Western medicine, discovers that his brother has liver cancer. Lastly, there’s the story of a Vietnamese American nail salon owner whose husband is diagnosed with hepatitis B, which was probably contracted by sharing razors with an infected roommate in college. No, these are are not vignettes from an Asian American film about coincidence. These are cautionary tales used in cultural, comic book-like photonovels that were developed to raise hepatitis B awareness among Asian Americans–the racial/ethnic group with the greatest risk of contracting hepatitis B.

chinese couple

“I have something important to tell you. Actually, i have chronic hepatitis B infection.”
“What? Why didn’t you tell me earlier?”

Hepatitis B is an infectious liver disease caused by the hepatitis B virus and is spread through contact with bodily fluids such as blood, semen, or vaginal fluids. It can also be passed from mother to child during childbirth. Contracting the virus can lead to either acute infection with symptoms that include liver inflammation, jaundice, fever, and nausea lasting several weeks or chronic infection, which may not present with symptoms but is a leading cause of life-threatening conditions such as cirrhosis (scarring of the liver) and liver cancer. Hepatitis B, however, is treatable and preventable through limiting exposure (i.e. not sharing needles, safe sex, etc.) and vaccinations.

ChronicHepatitisB_350px (1)

(image from CDC website)

Asian Americans, particularly recent immigrants, are especially vulnerable to hepatitis B infection because hepatitis B is endemic in many countries from which Asian Americans originate and Asian Americans have low rates of hepatitis B screening and vaccination. As a result, according to the CDC, of the estimated 1 million Americans with chronic hepatitis B about half are from the Asian/Pacific Islander (API) communities. For comparison, Asian Americans make up roughly 5% of the US population. Nearly 1 in 12 Asian Americans are chronically infected with hepatitis B, but many are unaware of their status. This further poses a public health risk since infected individuals can unknowingly spread the virus.

The low rates of hepatitis B screening and vaccination in the Asian American community may be due to a combination of barriers such as hepatitis B awareness, fluency in English, access to healthcare, and cultural beliefs and norms surrounding disease and medicine. To overcome some of these obstacles culturally-appropriate photonovels can be used to increase the effectiveness of a public health message. These are educational materials that use images of ethnic characters, cultural issues, and language to tell a story that is highly relatable to a target community. Photonovels, for instance, have been used with success to educate immigrant Latino communities on various health issues. The effectiveness of photonovels, however, have not been addressed for diverse Asian American communities which have do not have a unifying language such as Spanish for Latino communities.

korean family

“I’ve been feeling so drained these days, but now I’m much better, owing to my stone bed.”
“I should make you feel better. It cost us more than $2000!”

Faced with this obstacle, Sunmin Lee and her colleagues at the University of Maryland School of Public Health and Johns Hopkins Bloomberg School of Public Health developed three photonovels in Korean, Chinese, and Vietnamese languages with the help of focus groups from those communities. These focus groups aided in incorporating not only characters and simplified language into the photonovels, but also identifiable cultural norms such as the stigma of having a disease, misconceptions of traditional medicine and Western medicine, and the idea of luck and misfortune that surrounds disease.

storyline.medium

Summary of the storylines for each photonovel. Click for larger image. (Lee S. et al., 2013)

These photonovels were used as one component of a 90-minute hepatitis B educational program consisting of a video, slideshow presentation, and a Q&A session aimed at increasing hepatitis B screening rates to decrease the incidence of liver cancer among Asian American communities. A follow-up survey of participants was conducted a month after the educational program was delivered to evaluate the photonovel. A clear majority (nearly 90%) of survey respondents agreed or strongly agreed that the photonovels presented useful and easy-to-understand information on hepatitis B screening for liver cancer prevention. A similar majority of respondents also found that the stories were written by someone who was familiar with their respective communities (~77%) and a good teaching tool (over 80%). Perhaps most importantly, the authors of the study found that individuals who had never been screened for hepatitis B or were unaware of their infection status and who had evaluated the photonovels positively were more likely to indicate that they felt capable of and intended to undergo hepatitis B screening.

Furthermore, when the authors analyzed the responses based on income and education they found that individuals with less education and on the lower end of the income scale were more likely to evaluate the photonovels positively. Interestingly, when broken down by specific communities, Vietnamese respondents were most favorable overall towards the photonovels compared to their Korean and Chinese counterparts. Vietnamese participants also tended to be less highly educated, so the authors speculate that educational materials such as photonovels that rely on pictures more than text might be an effective strategy for this demographic. However, since the photonovels were all different it could be the case that the Vietnamese photonovel just happened to be better developed than the Korean or Chinese  photonovels and, therefore, more effective for the Vietnamese community.

vietnamese couple

“…Oh, by the way, honey, why were you mad at Aunt Mai?”
“She kept talking about liver infection and cancer! That’s so unlucky!”

The study, however, is not without its limitations. To start, it is a relatively small study of 347 survey respondents. The authors also caution that since their target population was not easily reached, participants were recruited through community organizations rather than through a random selection process. As such, the groups analyzed may not be representative of Asian American communities in the US. Additionally, the photonovels were one component of a larger educational program. Exposure to the 90-minute presentation may have primed the participants to read and understand the photonovels. It would be good to know how effective the photonovels are independent of the presentation as well as how it compares to educational materials that are more text-dependent or written in English. Lastly, to determine if this campaign effectively translates into higher hepatitis B screening rates, it would be essential to know how many of the participants ultimately underwent hepatitis B screening. As it stands, the survey only asked if the participicants felt capable of undergoing a hepatitis B screening and what their likelihood of undergoing a screening.

Despite its shortcomings, the positive reaction of the Korean, Chinese, and Vietnamese participants to the photonovels is encouraging. The study, although small, suggests that culturally appropriate photonovels may be an effective strategy for increasing hepatitis B awareness and lowering the liver cancer rates in the rapidly growing Asian American community. The study’s methods in consulting focus groups also provides a template for designing future public health education campaigns targeting other immigrant and at-risk populations.

In the meantime, if you’re Asian American don’t let the stigma of having a disease, traditional medicine, or the taboo of discussing illness stop you from getting screened for hepatitis B. Your liver might thank you for it later.

The photonovels are available as pdf here.

*Speaking of coincidence, May is Asian-Pacific American Heritage Month and Hepatitis Awareness Month.

References:

Lee S., Yoon H., Chen L. & Juon H.S. (2013). Culturally Appropriate Photonovel Development and Process Evaluation for Hepatitis B Prevention in Chinese, Korean, and Vietnamese American Communities., Health education & behavior : the official publication of the Society for Public Health Education, PMID:

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Médecins Sans Frontières Scientific Day 2013

By Lindsay Kobayashi
Posted: May 14, 2013
PLOS Medicine was one of the sponsors - check out the swag!

PLOS Medicine was one of the sponsors – check out the swag!

Last Friday, I had the fortunate opportunity to attend the Médecins Sans Frontières Scientific day at the Royal Society of Medicine in London.  If you didn’t get a chance to check out the coverage via online streaming or twitter, I’ll give a quick run-down of things here.

 

What is Médecins Sans Frontières?

Médecins Sans Frontières, or Doctors without Borders, or just simply MSF, is an international humanitarian aid organisation. MSF gives rapid, non-discriminatory emergency aid in situations of humanitarian crisis, such as during armed conflict, natural disasters, and disease epidemics. In 1999, MSF won the Nobel Peace Prize ”in recognition of the organization’s pioneering humanitarian work on several continents“.

 

What is MSF Scientific Day?

MSF conducts scientific research alongside the health care relief that they provide in emergency situations. For example, MSF responded to a major outbreak of lead poisoning among children in northern Nigeria in 2010. In addition to providing care for the affected children, MSF scientists conducted research among the children to determine the factors associated with neurological symptoms caused by lead poisoning and to assess the effectiveness of their treatment programme (research presented at the 2013 Scientific Day). The purpose of the Scientific Day is to disseminate this research produced by MSF scientists to the greater public.

 

So what?

As I learned throughout the day, the balance between providing health care in a crisis while conducting research is extremely delicate. MSF has to deal with many sensitive and ethical issues such as:

- How can resources be devoted to research when they are so badly needed for health care treatment, particularly in low-resource settings?

- How can it be ensured that the research conducted is high-quality, addressing the most important issues for the people who are the research subjects, and actually making a difference?

- How can scientific objectivity and neutrality be maintained in research when the humanitarian situation demands strong advocacy?

 

Things are now becoming a little more complicated. The morning sessions of the day covered results of recent research MSF has conducted, with exciting findings such as the positive effects of blogging among multi-drug resistant TB patients around the world and an effective TB treatment programme in Somalia, which is an extremely dangerous conflict setting. But, is conducting this type of research withdrawing precious resources from aid efforts, is the research addressing the big problems that the affected people are most concerned with, and is it having the highest impact possible? Enter Hans Rosling:

 

Lessons from Hans Rosling

If you have not heard of Hans Rosling, stop reading immediately and listen to his TEDTalk. Right now. Seriously, do it.

Hans Rosling is a Swedish medical doctor and academic who is one of 2012’s 100 Most Influential People in the World according to Time Magazine. He co-founded ‘Gapminder’, which is amazing software that makes data accessible and interactive for people to use – a ‘modern museum on the Internet’. He has a whole string of TEDTalks online and I recommend listening to any one of them to get fired up about making change and reducing inequality in the world.

Hans Rosling worked in Mozambique as a medical doctor in the early 1980’s and came to share with us his experience of working in a poor, low resource area where there were only two medical doctors for a population of 300,000 people. You must, must, must watch the video from his Scientific Day talk. He is a hilarious speaker and told an inspiring story about his experiences (including an encounter where Fidel Castro attempted to participate in designing his research study!).

I won’t rehash his talk (although it involved wildly jumping up on a table, almost knocking over a glass water jug, and sending his pointer stick flying across the room in the span of a minute), although he left us with three main lessons:

 

  1. If you are responding to a humanitarian crisis and want to conduct research, you need extra resources. When human lives are at stake and you have few resources to begin with, health care is the priority;
  2. If you are in a situation where politics can influence your work (the Fidel Castro situation), you must define who you are: a researcher. That means being as unbiased, neutral, and as objective as one can be and not letting yourself be used as a political pawn;
  3. If, as a humanitarian response, you do something perfectly, you have taken a resource away from somewhere else where it could have been used. Listen to the people who are affected and give them what they need, rather than aiming to be the “perfect” humanitarian aid worker. You will never do it, and you don’t want to leave a place in a situation where your intervention is not sustainable.

 

Thank you, Hans

Thank you, Hans

In short, it was an extremely enlightening and thought-provoking day. The issues brought up are extremely important to human health, development, and rights and we need to be having conversations about these issues. Please check out the online feed of the Scientific Day (it won’t be available online until May 17th, but you can see the posters for now), take a look at Gapminder, and comment below or on twitter (#MSFSci) to continue the discourse!

 

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Patient Zero: The origins of disease

By Atif Kukaswadia
Posted: May 7, 2013

Better Know An Epidemiologist/History of Epidemiology is an ongoing feature where we highlight important studies that have been significant breakthroughs in public health. All of the articles are listed here.

Gaetan Dugas, Air Canada flight attendant and one of the first diagnosed cases of HIV

Patient Zero is a common infectious disease epidemiology term. It refers to the first known case of the disease of interest, and is useful when tracking disease outbreaks. Knowing where the disease starts allows us to track not only the spread of the disease, but also how it spreads – through water, air, person-to-person contact etc.

I heard an absolutely phenomenal podcast through WNYC’s RadioLab podcast about Patient Zero, and that formed the inspiration for this post. I highly recommend listening to it when you have a chance – either through iTunes, on their website. They cover several different “Patient Zero’s,” including Typhoid Mary and Gaetan Dugas (pictured above).

Today, I’ll be talking about Typhoid Mary. To listen exclusively to the Typhoid Mary segment of the RadioLab podcast, click here.

Click the image to go to the RadioLab podcast about Patient Zero.

A historical poster cautioning people against acting like Typhoid Mary (pic goes to Wikipedia article)

Mary Mallon was born September 23rd, 1869, and is of interest to Epidemiologists as she was the first known asymptomatic case of typhoid fever. Typhoid fever is estimated to affect between 16 – 33 million people annually. Fatalities from typhoid drop to less than 1% if treated quickly with oral rehydration therapy. However, when untreated, death occurs in 10% – 30% of those infected (for more information about the disease itself, check out this excellent Infection Landscapes post). The name is derived from the Greek word “typhus” or stupor, as infected individuals suffer from malaise and a high fever. It is spread through the feces of contaminated individuals, generally after those feces come into contact with either food or water. The typhoid bacteria can be destroyed by cooking food thoroughly and boiling water before drinking it. Washing hands and cleaning dishes also prevents transmission of the bacteria.

Now back to Mary Mallon. Mary was born in Ireland, and moved to the US in 1884. She was a cook, and in 1900, she was working for a family in Mamaroneck, NY. Soon after she started there however, the residents developed typhoid fever. She moved to Manhattan in 1901, and worked for a new family. Sure enough, this family developed typhoid fever also. After this, she moved to Oyster Bay, Long Island, infecting a third family.

George Soper, a typhoid researcher, found Mary was the link between the first three families, and approached her to obtain a stool and blood sample. As you can imagine, this conversation didn’t go over well – not only was there no prior evidence for asymptomatic typhoid fever, this isn’t exactly something you can ask someone for after accusing them of making people sick (or at any time really). Adding to this was the anti-Irish and anti-immigrant sentiment of the time, feeding Mary’s view that she was being unfairly persecuted.

Soper published his findings as a case-report in JAMA, charmingly entitled “The work of a chronic typhoid germ distributor.” Mary chased him away multiple times, wielding kitchen utensils as weapons. Soper wrote about his experiences in a 1939 article in the Bulletin of the NY Academy of Medicine.

Dr Sara Baker was sent to Mary Mallon’s house, as it was felt that a female doctor may be more persuasive than a male. After being refused again, Dr Baker went to Mary’s workplace with police officers, and had her arrested. Mary was tested, deemed to be a carrier, and placed in isolation on North Brother Island.

Part of the New York American article of June 20, 1909, which first identified Mary Mallon as “Typhoid Mary.” Photo Credit: New York County Clerk Archives via Planck’s Constant (click pic to go to their site)

Mary was kept in isolation from 1907 to 1910. However, in 1910 the New York State Commissioner of Health decided that disease carriers should no longer be kept in isolation, and so Mary was allowed to return to work, provided that she did not work as a cook. She left, and started working as a laundress, washing clothes. However, this paid less, so she adopted the name Mary Brown, and returned to life as a cook. She got a job working at New York’s Sloane Hospital for women, and is suspected to have infected a further 25 people with typhoid fever before being caught by the health authorities again in 1915. She was sent back to isolation, and lived out the rest of her days there. She passed away on November 11th, 1938 from pneumonia.

But wait. Something doesn’t sit right here.

The bacteria can be destroyed by washing hands, using clean utensils, and above all, by cooking food thoroughly. So how did Mary Mallon transmit the disease? Assuming she kept her hands clean, cooked food thoroughly and cleaned plates, she shouldn’t have passed it on right?

For the answer, you’ll have to listen to RadioLab’s podcast. And trust me, it’s worth it.

Ed note: A version of this post originally appeared on Mr Epidemiology back in January 2012

References:

SOPER, G. (1907). THE WORK OF A CHRONIC TYPHOID GERM DISTRIBUTOR. JAMA: The Journal of the American Medical Association, XLVIII (24), 2019-2022 DOI: 10.1001/jama.1907.25220500025002d

Soper GA (1939). The Curious Career of Typhoid Mary. Bulletin of the New York Academy of Medicine, 15 (10), 698-712 PMID: 19312127

http://cythereabast.wordpress.com/2007/02/20/the-board-of-healths-exile-of-mary-mallon-was-it-justifiable/

http://history1900s.about.com/od/1900s/a/typhoidmary.htm

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Do we have something against red meat, or just complexity?

By Beth Skwarecki
Posted: May 1, 2013

We’ve thought for decades that red meat is unhealthy. Earlier this month we found out why, a neat story involving a molecule called carnitine found in meat, metabolized by the bacteria that live in our gut. The resulting chemical, according to studies in mice, is linked to heart disease. Here is the paper. Open and shut case? That would be nice, but no.

There is a larger and more uncomfortable story here, and I don’t mean the fact that they got a vegan to eat a steak for science. (Although I would love to have heard that conversation.)

Sirloin Steak, Baked Potato, and Sauteed Carrots

Let’s eat some steak … for science!

 

Here’s what I mean. The carnitine study was shouted from the rooftops, or the New York Times which is basically the same thing. But two more studies that came out in the following weeks resulted in less-than-triumphant coverage: one agreed with the first study, but opened up the complexity of the metabolic pathway involved. No longer just carnitine and TMAO, this one mentioned lecithin, choline, and betaine.

The other study claimed that carnitine, as a supplement, protects against heart disease. This meta-study looked at outcomes in patients who had already had one heart attack, and were assigned to take carnitine or placebo. The supplement was associated with lower risk of death, angina, and arrhythmia – but not heart attacks themselves, which is already a little weird.

Who is right? Well, they looked at different things. MedPageToday published what amounted to a mostly polite argument between the authors of the two studies. The pro-carnitine researcher pointed out that his study concluded that carnitine was good for humans, by studying carnitine and its outcomes in humans, while the other study involved mice, biochemistry, and small sample sizes (one single human being stood in for all of vegan-hood). His anti-carnitine counterpart reminded readers that meta-analyses often produce “apparent statistical results that don’t hold up on further direct experimental testing.”

They’re each right about the flaws in the other’s methodology, but that doesn’t help us much if we’re trying to decide whether to avoid meat or start taking a carnitine supplement. Which brings us to the question of what these chemicals are, anyway.

Francisco de Goya y Lucientes - Still-Life - A Butcher's Counter - WGA10068

A Butcher’s Counter by Francisco de Goya y Lucientes

Carnitine is an amino acid found in meat, hence the name, and apart from its possible cardioprotective effects is used as a supplement in energy drinks and for athletes, despite a lack of convincing studies saying that it does anything. (If a chemical can be sold in pill or powder form, you can guarantee that there is an article on bodybuilding.com aiming to convince you, the muscle-seeking reader, that you must buy some. Here is the article for carnitine.)

The risk-raising molecule in the first study was TMAO (Trimethylamine N-oxide), which the researchers concluded was made out of carnitine by gut bacteria. Carnitine-rich meals resulted in high levels of blood TMAO, but if the subjects took an antibiotic first, TMAO levels stayed flat. That was in the subjects that were used to eating meat. The vegetarians and vegans’ TMAO levels stayed low when they ate carnitine, whether it was from a pill or a steak. The mouse component of the study established the link between TMAO and heart disease, at least in one heart-disease-prone strain of mice.

Predictably, fans of meat-rich diets did not like this study. This article from Beef Magazine earnestly appeals to beef’s “good taste” as a counter-argument. More seriously, paleo diet fan Chris Masterjohn took the study to its logical conclusion: if meat is bad for you because it produces TMAO, then other foods that produce TMAO in the body should be bad for you too. These foods include lecithin, found in eggs (and added to foods like chocolate, mmm chocolate) and – the biggest culprits of all – fish and shellfish. They have massive amounts of TMAO; in fact, its precursor trimethylamine is known for its fishy smell. People who cannot convert trimethylamine to TMAO have what’s called fish odor syndrome.

Within a week, the other shoe dropped. The same researchers that published the first carnitine-is-bad study (Stanley Hazen’s group at the Cleveland Clinic) came out with another paper about lecithin. Expanding on a similar 2011 paper, this study associated TMAO with heart disease risk in humans. Once again, food (in this case, egg yolks) resulted in higher TMAO levels. The effect was gone, however, after a course of antibiotics.

What’s really amazing here–whether the results hold up or not–is that we are finally hearing about what gut bacteria do, not just who they are. Many studies on our internal ecosystems are just cataloguing the players, creating a modern-day version of the medieval bestiary without really understanding how the species interact and what they do for us. The meat-eaters, for example, had guts dominated by Prevotella bacteria, but who’s to say Prevotella was the microbe responsible for making TMAO, or even that meat-eating was what caused the TMAO makers to grow in meat-eaters’ stomachs? There is evidence linking Prevotella to consumption of whole grains, so the dietary culprit, if there is one, could be a meat/grain combo.

Sloane278 f.48v Elephants,Dragon,AndMandrake

Page from a medieval bestiary

There are hundreds of species in our intestines, many of which we can’t grow in the lab, and the tough questions of what exactly they do, how they interact, and how they make use of our food are not ones we are currently able to answer with any sense of completeness. We have crude tools that have only advanced a little since the must-read parables of the geneticist and biochemist. (I’ll wait while you read the whole thing, but here’s a taste: Trying to understand how cars are made, the biochemist grinds one up and announces that cars are 10% glass, 25% plastic, 60% steel, and 5% other. Meanwhile, the geneticist ties the hands of workers going into the factory and examines how and whether the resulting cars crash. He concludes that seatbelts are vestigial since the cars still function without them.)

I wrecked this car for science!

The other reason these studies are hard to wrap our heads around, aside from the sheer complexity of the question (what else was in that steak, anyway? Does it matter if it was grass-fed or factory farmed? How similar is one carnivore’s gut microbiome to another’s?) is that we like answers we can act on now. I can read a study about steak today and switch to veggie burgers tomorrow. Messing with diet is popular because it’s totally within our control and we can do it three times a day. Popping a pill is not much more of a commitment, but understanding the metabolic pathways of a collection of symbiotic organisms? That’s going to take a little longer.

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More Treatment, Less War: The White House Drug Policy Reform

By Jason Silverstein
Posted: April 26, 2013

Many people who want substance abuse treatment can’t get it. The White House wants to fix this. Can they do it, and will it help?

On Wednesday, April 24, the White House Office of National Drug Control Policy (ONDCP) released its 2013 National Drug Control Strategy. They say their position has evolved. “We cannot arrest or incarcerate our way out of the drug problem,” they write. No longer do they see the nation’s drug problem as primarily a criminal justice matter. They see it as a public health issue. And because they see it as a public health issue, their new report – which they call a 21st century approach – spends a lot of ink on access and treatment.

Here the ONDCP gives us the broad strokes on why it cares about expanding access to treatment – and why we should, too:

Research shows that addiction is a disease from which people can recover. In fact, success rates for treating addictive disorders are roughly on par with recovery rates for other chronic diseases such as diabetes, asthma, and hypertension.
Recognizing this, the Obama Administration has taken unprecedented action to expand access to treatment for millions of Americans. Through the Affordable Care Act, insurance companies will be required to cover treatment for addiction just as they would cover any other chronic disease. We estimate that with the Affordable Care Act, 62.5 million people will receive expanded substance abuse benefits by 2020, with 32.1 million gaining those benefits for the first time. To support this expansion, the President’s FY 2014 Budget includes an increase of $1.4 billion for treatment over the FY 2012 amount, the largest such request for treatment funding in decades.

"No More Drug War Rally.” Nikki David and Neon Tommy. CC BY 2.0, 2011.

“No More Drug War Rally.” Nikki David and Neon Tommy. CC BY 2.0, 2011.

Here’s where we stand. Only one in ten people who need substance abuse treatment get it. In 2011, this meant that nearly 22 million people needed treatment, but only 2.3 million received it. Of the remaining 19 million, many did not think they needed help. But those who wanted help, and made an effort to get it, and still could not, shared common barriers. Nearly half ran into an insurance wall. 37% did not have health insurance and could not afford to pay for it. Another 10% had health insurance, but it did not cover treatment. The Affordable Care Act promises to fix this.

Here’s another way the ONDCP wants to help. In their lengthy report, they cite – and praise – the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Access to Recovery Program. This program provides “grants to states and tribes to provide vouchers to people who are seeking or are in recovery, enabling them to choose the treatment and recovery support services they need.” These services aren’t clinical. They help provide job networks and stable housing. In Missouri, for example, their program has a focus on “social connectedness.” And they also provide faith-based recovery support.

It looks like the Access to Recovery program works. SAMSHA reports that 82.1% had no substance abuse within a month of services and 96% had reduced or no involvement with the criminal justice system.

We’ve seen similar positive results elsewhere. In 2009, researchers from the University of Washington and Washington’s Department of Social and Health Services published a study on the impact of Access to Recovery programs in their state. The team started by identifying program clients and creating a comparison group. To achieve similarity of the groups, they matched by five variables (substance abuse treatment history, arrest history, employment history, Medicaid utilization, and health status).

They also found benefits for the Access to Recovery Program. In their study, clients stayed in treatment for 42.5 days longer and stayed employed at a rate 1.6 times greater than those who did not participate in the program. But they also found that timing is important. Here, the target seemed to be 31 to 180 days after a client started substance abuse treatment.

Timing matters. In 2011, Christy Scott and colleagues published a paper on substance abuse treatment, abstinence, and mortality. They found treatment beneficial – as long as you got it early.

This is an impressive study. They recruited their sample of 1326 people between 1996 and 1998 and followed them for 9 years. During this period, 131 participants died – or 11%, nearly 3 times the rate of their community.

Here’s what they found. If a person participates in a substance abuse treatment program early, then they’ll likely see a benefit. But if the person participates later in life, or spends a longer period of his or her life in treatment facilities, then this benefit seems to vanish. The researchers argue that this means addiction follows a chronic disease model.

Much of the drug war is justified by moral claims. But when people lose 22.5 years of their life because they receive punishment when they should receive treatment, there’s nothing moral there. If we give people only punishment, and not treatment, and send them back into their old communities with fewer resources and greater disadvantage, we shouldn’t ask what is wrong with them. We should ask what is wrong with us.

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Selling Science: Marketing Public Health Messages

By Atif Kukaswadia
Posted: April 15, 2013

Think about the most recent message you heard on TV. If you’re like me and watch a lot of sports it probably had something to do with going “All in for Week 1.” Alternatively, maybe you’re thinking about Importing from Detroit. Or maybe you want to see a day in the life of LeBron’s Samsung Note II. But how often do we see effective marketing of public health messages?

When it comes to public health, how much time do we spend promoting our message? Perhaps the only “public health” messages people see relate to two things: 1) phamarceuticals (although this varies by region) and 2) seasonal vaccination programs. The way advertisers think about messaging is markedly different to the way public health professionals think and thus how we convey information. Rather than talk about how to “communicate a health risk” maybe we should think about how to “market a message.” It’s a simple, but seismic shift.

Currently, we use a process known as Knowledge Translation. This is defined by the Canadian Institutes of Health Research as “the exchange, synthesis and ethically-sound application of knowledge—within a complex system of interactions among researchers and users—to accelerate the capture of the benefits of research for Canadians through improved health, more effective services and products, and a strengthened health care system.”In short, it’s based in science, evidence, and is undeniably an awesome step forward for making science accessible to the public and knowledge users. There are many ways to approach knowledge translation, and for an excellent overview of Knowledge Translation and their frameworks, check out this review by Sudsawad. But if we’re missing one thing, it’s making these programs catchy and memorable to non-scientists, which is where marketing and business training is invaluable. These are people who think very differently than scientists, and whose experience and perspectives can help our programs become even better and more effective.

This isn’t to say that people aren’t doing it already. There are some very effective public health advertisements that have been conducted, and those are what led to the genesis of this piece – when some campaigns are really good, you wonder why they all can’t be.

An example of the excellent ad campaign by Preventable (more info available at their site)

An example of the excellent ad campaign by Preventable (more info available at their site)

An example is the excellent ad campaign that Preventable conducted in British Columbia, Canada. They launched a number of guerilla public health ads (one of which is featured above), where they appealed at people’s sense of “invicibility” by putting up signs that said (among other things) “drowning only happens to other people” and “you probably won’t need a helmet today.” The message is simple, but very effective.

While this uses more “traditional” media, the ubquity of social media means you can attempt to create videos with the hope they will go viral. One of my favourites was the video above entitled “The Real Bears” where the Centre for Science in the Public Interest partnered with Grammy-winning artist Jason Mraz to create a (catchy) music video filled with information about soft drink consumption and its effects. Using the polar bears commonly associated with a large soft drink manufacturer, they talk about many of the health concerns associated with excessive soft drink consumption that have been shown in the scientific literature.

A third example is the Quit the Denial campaign recently launched by the Ontario Ministry of Health. Using Facebook and YouTube, they crafted an absolutely brilliant ad campaign targetting social smokers and the typical “excuses” social smokers make to differentiate themselves from regular smokers, where they draw parallels between social smoking and “social farting” or “social nibbling.” Using commonly heard justifications for being a social smoker – “I only smoke with friends” or “I never buy my own cigarettes” they created a very interesting ad campaign. It’s a great ad, and hits that sweet spot between informative and hilarious that makes it fantastic for viral marketing.

http://www.youtube.com/watch?v=fb5q2eie4ko

But that leads to the obvious criticism of these methods: Do they work?

One of the big problems is how do you actually evaluate these methods. For example, I found the “social farter” ad hilarious. I shared it on Twitter and Facebook, and many friends “liked” it, “shared” it, and “retweeted” it. But how many of those were social smokers to begin with? Did this actually lead to any behaviour change, or did it make social smokers feel marginalized and reinforce behaviours?

A recent review published in Tobacco Control by Durkin and colleagues sought to evaluate the role of “Mass Media Campaigns.” This study built off a previous study published by the National Cancer Institute and another study by Melanie Wakefield and colleagues. They did an analysis of population-based interventions and looked for measures of people who quit smoking pre- and post-intervention. Durkin and colleagues found:

There is strong empirical evidence that, within the context of comprehensive tobacco control programmes, MMCs (Mass Media Campaigns) can promote adult quitting and reduce adult smoking prevalence. Effectiveness may depend upon campaign reach, intensity, duration and the messages used.

….

Head-to-head comparative studies of message themes find that NHE (Negative Health Effect) messages, many of which feature graphic imagery and/or testimonial stories and elicit negative emotions, tend to perform well, compared with messages without such features.

While the above is positive, that’s not to say it always works. A study by Flynn and colleagues that focused on Grade 7-12 students found no effect of a mass media intervention. A systematic review of web-based interventions performed by Hutton et al. found that there was insufficient evidence to draw conclusions about their effectiveness, although they do suggest that their findings reveal important practices that can make future interventions more effective.

I’ll leave you with this quote from Tim Johnson, who was the Medical Editor for ABC News and wrote the foreword to the NCI report on The Role of the Media in Promoting and Reducing Tobacco Use:

Tobacco use is a social phenomenon largely propelled by mass media over the past century, led by tobacco industry professionals who constantly change strategies to reach their goals. They combine the resourcefulness of a profi t-making industry with a changing media and regulatory landscape to sell a product that remains our greatest public health challenge. We will not remove tobacco from our society unless we are willing to understand the industry’s constantly changing tactics.

With the sheer amount of information available to us, and the plethora of avenues we have to disseminate that information, I wonder: should we be training PhD/MSc/MPH students in business and marketing methods in addition to knowledge translation frameworks we have developed? When we design interventions, should we design ads and campaigns incorporating a marketing perspective in addition to scientific principles? Or should we adapt our current frameworks and guidelines using principles of marketing that we, until now, may not have considered?

Thanks to Colleen W. and @alanaspira for help in preparing this piece.

References:

Bala MM, Strzeszynski L, Cahill K. Mass media interventions for smoking cessation in adults. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD004704. DOI: 10.1002/14651858.CD004704.pub2. Available online here.

Davis RM, Gilpin EA, Loken B, Viswanath K, & Wakefield MA. The role of the media in promoting and reducing tobacco use. Health, 1998 98, 4302. Available online here.

Durkin S., Brennan E., Wakefield M. Mass media campaigns to promote smoking cessation among adults: an integrative review. Tob Control 2012;21:127-138 doi:10.1136/tobaccocontrol-2011-050345 Available online here.

Hutton, H. E., Wilson, L. M., Apelberg, B. J., Tang, E. A., Odelola, O., Bass, E. B., & Chander, G. (2011). A systematic review of randomized controlled trials: web-based interventions for smoking cessation among adolescents, college students, and adults. Nicotine & Tobacco Research, 13(4), 227-238. Available online here.

Sudsawad, P. (2007). Knowledge translation: Introduction to models, strategies, and measures. Austin, TX: Southwest Educational Development Laboratory, National Center for the Dissemination of Disability Research. Retrieved April, 14, 2008. Available online here.

Wakefield, M. A., Loken, B., & Hornik, R. C. (2010). Use of mass media campaigns to change health behaviour. Lancet, 376, 1261-71. Available online here.

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Immigration Reform: A Second Chance for Undocumented Immigrant Health?

By Viet Le
Posted: April 9, 2013

When the Affordable Care Act was signed into law in March of 2010, many immigration advocates were disappointed that the bill left undocumented immigrants out in the cold. While the law kickstarts the process of bridging the gap for millions of uninsured Americans, specific language was written into the legislation to bar undocumented immigrants from being “eligible for public insurance or any type of private coverage obtained through exchanges.” At the time of the bill’s signing, approximately 7 million out of an estimated 11 million undocumented immigrants in the US were without insurance, and many of whom were living in poverty. These numbers are only expected to increase [1]. With immigration reform highly visible in Obama’s second term, immigration advocates are now viewing this as a second chance to address a growing public health concern.

rally 200

Immigration rally in Miami

Immigration reform that includes either a path to citizenship or gaining recognition as legal residents would “open the door” for unauthorized immigrants to health insurance and ultimately better health care. But any consideration of immigration reform engenders debate that can quickly turn divisive. Do undocumented immigrants have a right to citizenship? How would “amnesty” affect the economy, employment, social services and other federal programs in the US? Would subsidizing health insurance for 7 million additional people increase costs to the government? Or would it drive costs, such as health insurance premiums, down? This has been suggested because immigrants, both legal and undocumented,  incur less heathcare costs (although, this might be a reflection of their lack of access to healthcare to begin with), while undocumented immigrants tend to be young and healthy. This of course doesn’t reflect the reality for all undocumented immigrants who make up a significant proportion of the migrant labor workforce–a group associated with significantly poor health [2].

One of the public health fears that citizens who want stricter border control have is that undocumented immigrants are transporting or spreading communicable diseases like HIV or leprosy as Lou Dobbs once proclaimed. Seemingly confirming these fears, last November there were reports of “a man from Nepal who carries a severe multi-drug resistant form of tuberculosis was detained by Border Patrol when he illegally crossed into the country near McAllen after staying in Mexico for a week.” Assuming that undocumented immigrants are bringing diseases into the country than increasing border security does nothing to deal with diseases already potentially in the country. Bringing undocumented immigrants into the healthcare fold would.

It is often noted that since undocumented immigrants lack insurance and access to healthcare, many forgo routine, preventative checkups with primary care physicians. Instead, many undocumented immigrants receive healthcare services from hospital emergency rooms–often times waiting until an injury or illness becomes serious before seeking treatment. This puts a burden on the healthcare system since emergency room visits are expensive and are paid for by the government through programs like Medicaid. Consistent with entering care later, a recent study in PLOS One found that undocumented Hispanic immigrants that sought care at a HIV free clinic in Houston presented with features of HIV infection that were more advanced than their legal resident counterparts [3]. Although, once in care undocumented Hispanic immigrants fared just as well, if not better, than legal residents with HIV.

Making matters worse, fear of deportation also represents a psychological barrier for unauthorized immigrants to seek healthcare [4]. A smaller scale study reports that the impact of this fear is twofold as it not only prevents some from seeking treatment but also exerts mental health stress [5]. Furthermore, these effects also extend to legal immigrants who feared deportation as a result of unfamiliarity with US immigration policies.

As of this week, immigration reform seems tantalizingly close (although, we all know legislative looks can be deceiving). The bipartisan “Gang of Eight” expect a comprehensive bill overhauling immigration by the end of this week. Some of the details being hammered out are agreements between unions and business for a “low-skilled worker visa” and if and how a pathway to citizenship would be implemented (undocumented immigrants could be waiting as long as 8 to 10 years before they can even begin the process of naturalization). Immigrant communities and advocates, however, will not be sitting idly on the sidelines as they plan to rally in Washington D.C. on Wednesday.

 

References

1. Zuckerman S., Waidmann T.A. & Lawton E. (2011). Undocumented Immigrants, Left Out Of Health Reform, Likely To Continue To Grow As Share Of The Uninsured, Health Affairs, 30 (10) 1997-2004. DOI:

2. Holmes S.M. (2006). An Ethnographic Study of the Social Context of Migrant Health in the United States, PLoS Medicine, 3 (10) e448. DOI:

3. Poon K.K., Dang B.N., Davila J.A., Hartman C., Giordano T.P. & Okulicz J.F. (2013). Treatment Outcomes in Undocumented Hispanic Immigrants with HIV Infection, PLoS ONE, 8 (3) e60022. DOI:

4. Maldonado C.Z., Rodriguez R.M., Torres J.R., Flores Y.S., Lovato L.M. & Goldstein J.N. (2013). Fear of Discovery Among Latino Immigrants Presenting to the Emergency Department, Academic Emergency Medicine, 20 (2) 155-161. DOI:

5. Hacker K., Chu J., Leung C., Marra R., Pirie A., Brahimi M., English M., Beckmann J., Acevedo-Garcia D. & Marlin R.P. & (2011). The impact of Immigration and Customs Enforcement on immigrant health: Perceptions of immigrants in Everett, Massachusetts, USA, Social Science & Medicine, 73 (4) 586-594. DOI:

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Twitter study of vaccine messages: opinions are contagious, but in unexpected ways

By Beth Skwarecki
Posted: April 5, 2013

Remember 2009? The H1N1 pandemic we were all waiting for? I do. I was pregnant; H1N1 was particularly risky for pregnant women. The vaccine wasn’t available until after I had my baby, but when they held a clinic an hour north of where I live, I brought my husband there so we could both get our shots. My infant son was too young to be vaccinated, so I wanted to protect him through herd immunity.

President Barack Obama gets the H1N1 vaccine on Dec. 20, 2009.

A study came out today on twitter messages from that time. How did pro-vaccine sentiments spread, versus anti-vaccine ones? Which messages were more contagious?

I talked to one of the authors, Marcel Salathe, today. He’s an infectious disease researcher studying the spread and transmission, not (just) of disease, but of information. “We assume people infect each other with opinions about vaccinations,” he said, and the H1N1 scare was a good opportunity to put some of his group’s theories to the test.

They collected nearly half a million tweets about the H1N1 flu vaccine. In 2009, H1N1 wasn’t included in the regular flu shot, and became available partway through flu season as a separate dose. With a possible pandemic looming, people had plenty of motivation to get the vaccine and encourage others to get it—but anti-vaccine sentiments were in circulation too.

The result, striking but perhaps not surprising: negative opinions were more contagious than positive ones. (Specifically, someone who read a lot of anti-vaccine messages was more likely to follow up by tweeting or retweeting negative messages of their own.)

What’s more, being exposed to a lot of positive messages also predicted negativity. Salathe interprets this as a sign of public health messages backfiring: maybe they’re being seen as pushy.

I asked him, is it just that people can be passionate about being anti-vaccine, but nobody is passionate about “yeah, I got my flu shot”? He says maybe not: people who are pro-vaccine are often concerned that those who don’t vaccinate are putting others at risk. On the other hand, the anti-vax folks included people who sent out hundreds of negative tweets; nobody had that kind of enthusiasm on the positive side.

The research really didn’t get into the content of the tweets. In fact, they were categorized as positive or negative by students who read just 10% of the tweets. Computers, following the humans’ lead, automatically tagged the rest. (If you’re interested in the methods, the paper is open access, and the Salathe group’s website is also full of fun reads. If you find statistics and computational analysis fun, that is.)

Network diagram of twitter users tweeting positive (green) and negative (red) messages about the vaccine. Salathé lab, Penn State University

Network diagram of twitter users tweeting positive (green) and negative (red) messages about the vaccine. Salathé lab, Penn State University

Does sharing ideas mean sharing germs?

Seth Mnookin has said that people are drawn to groups critical of vaccines because those groups provide a supportive community, especially for parents of kids with autism. I thought about that when reading this paper, about the “echo chamber” style clusters of opinion the researchers found.

In real life, a cluster of people who don’t vaccinate is a potential hotspot for an outbreak. I asked if people who get that supportive community online might be less of a threat to herd immunity: their buddies could be anywhere in the world, well out of germ-sharing range.

Salathe pointed out that past research has shown that people’s online contacts tend not to stray too far geographically: if you live in San Francisco, you’ll have more contacts in the bay area than you would if you lived in another part of the country.

What would this study look like on facebook, I wondered? (Salathe doesn’t have that data.) In my experience, people who are friends on facebook often know each other in real life: On twitter, I follow scientists, science writers, and interesting people the world over. Meanwhile, most of my facebook friends are my actual friends. The local La Leche League has a lively facebook page, as does my son’s preschool.

This landscape is changing all the time. In 2009, Twitter had about 18 million users; that’s since grown more than tenfold. Facebook, meanwhile, has over a billion.

“Ten years ago we talked about Dr. Google; now we can start to talk about Dr. Facebook and Dr. Twitter,” Salathe said. “People get their information [about health and disease] from social networks.” On the bright side, this means well-crafted public health messages could go viral too. If what we read online influences what we do in meatspace, like getting vaccinations, that could have a big impact.

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The Not-so-Sweet Politics of Sugar Consumption

By Lindsay Kobayashi
Posted: March 28, 2013

sugar

What do you picture when you think of the food industry in your country?

In the United States, for example, the food industry is dominated by various big corporations that produce processed foods and regulate the production of meat, dairy, and agriculture (for a wonderful book on the American food chains, see The Omnivore’s Dilemma by Michael Pollan). In most highly developed countries like the United States, food is a consumer product. The sad truth is that the bottom line for most food industry corporations is profit, rather than delivery of properly nutritious diets (1). And we, as consumers, have the unfortunate responsibility of educating ourselves and being cognisant of the war being waged against our health at the supermarket. While endless material can be written about any one aspect of the food industry, this post will spotlight one single food: sugar. The sugar industry is becoming known as “Big Sugar” as its various production and marketing tactics come to light (and yes, they mirror those employed by “Big Tobacco”).

I don’t need to tell you that sugar is bad for you. We all know that sugar is linked to serious health conditions that characterise major 21st century causes of death, including diabetes, obesity, and heart disease (2-4). However, the causal role of sugar in the obesity epidemic is still a subject of hot debate today. Part of the trouble is the sugar industry’s major stakeholder role, combined with a lack of high-quality scientific evidence (5): for example, it is difficult to find population “controls” who do not consume sugar, which are needed for a proper examination of sugar’s health effects. The World Health Organisation will soon update its global recommendations for sugar intake, and has commissioned a systematic review and meta-analysis of the effects of sugar intake on body weight, which was just published open-access two months ago in the British Medical Journal (2). The results of the review suggest that sugar increases body weight through promoting overconsumption of food (2). The addictive sweetness of sugar combined with the general poor quality of direct evidence for sugar’s negative health effects combine to make a marketing dream for sugar companies.

Evidence for the “Big Tobacco”-style marketing tactics used by the sugar industry has recently been uncovered by an American dentist named Christin Couzens. A couple of years ago, Couzens noticed a funny thing while at a dental conference on diabetes and gum disease – sugar was not once mentioned as a cause of either health problem by any of the conference speakers. This incident began her on a journey of research into sugar industry archives. One of the most staggering things Couzens found was documentation of three sugar executives receiving an award called “The Silver Anvil” – for “excellence in the forging of public opinion” (5). In the 1970’s, these men had launched a highly successful campaign to save the public image of sugar when scientific evidence of its ill health effects had begun to emerge – with the eventual end results of the American Heart Association and American Diabetes Associations approving sugar as part of a healthy diet. I’ll save you the full summary: click here to check out the full article published by Couzens along with science writer Gary Taubes.

Clearly, various conflicts of interest stemming back to the sugar industry’s interest in profit have played a role in the current state of things today. It’s crazy that we are still having a scientific debate about the role of sugar in obesity. Recent work published in the British Medical Journal and by proactive health care professionals like Couzens show that our discourse about sugar is still evolving, and may take a positive turn for public health. Keep an eye out for the new forthcoming sugar intake recommendations by the World Health Organisation – what they conclude and how scientists, health care professionals, and most importantly governments respond will be the next key deciding factor on the role in sugar in the public’s health. In the meantime, recognising yourself as a consumer and taking the time to educate yourself about the politics behind the food you eat is the first step toward winning your own battle against big food corporations.

Below are a few related resources that are worth checking out:

Blogs

Sugar Politics: this is the blog that Cristin Couzens began after her research into sugar industry archives. The title says it all, in terms of description.

Food Politics: a long-running and famous blog by Marion Nestle, an American nutritionist and professor. The blog covers the general politics of food in America.

Newspaper Articles

The CBC: A recent Canadian article series on Cristin Couzens’ research

Time: Another recent article comparing Big Soda to Big Tobacco

Salon.com: A brief article summarising a recent report by Harvard researchers estimating that soda may cause of over 180,000 deaths per year, and the response from the American Beverage Association

Documentaries/Videos

Sugar: The Bitter Truth: a talk from an American paediatrician, Robert H. Lustig on the negative health effects of sugar – this video has over 3 million views on YouTube.

The CBC (again): A documentary by the CBC on the political history of sugar. Part 1 and Part 2.

References

1)      Stuckler D, Nestle M. Big Food, Food Systems, and Global Health. PLoS Med 2013; 9(6):e1001242. doi:10.1371/journal.pmed.1001242

2)      Te Morenga L, Mallard S, Mann J. Dietary sugars and body weight: systematic review and meta-analyses of randomised controlled trials and cohort studies. BMJ 2013; 346:e7492 doi: http://dx.doi.org/10.1136/bmj.e7492

3)      Liu S, Willett W, Stampfer MJ, Hu FB, Franz M, Sampson L, et al. A prospective study of dietary glycemic load, carbohydrate intake, and risk of coronary heart disease in US women. Am J Clin Nutr 2000; 71(6):1455-61.

4)      Malik VS, Popkin BM, Bray GA, Despres J-P, Willett WC, Hu FB. Sugar-sweetened beverages and risk of metabolic syndrome and type 2 diabetes: a meta-analysis. Diab Care 2010; 33(11):2477-83.

5)      Willett WC, Ludwig DS. Science souring on sugar. BMJ 2013; 346:e8077. doi: http://dx.doi.org/10.1136/bmj.e8077

6)      Taubes G, Kearns Couzens C. Mother Jones [Internet]. San Francisco: Mother Jones; November/December 2012 [cited 2013 March 28]; Available from: http://www.motherjones.com/environment/2012/10/sugar-industry-lies-campaign

Image source

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How Discrimination Links Lives Together

By Jason Silverstein
Posted: March 19, 2013

Recently, I wrote a piece for The Atlantic on how racism is bad for the body. For the bulk of the essay, I discuss how racism harms a single person’s health directly – and I link public health research with the NYPD’s stop and frisk policy. But at the end of the piece, I write:

… no person discriminated against is an island. When conditions of social injustice affect this many people, and prompt poor health outcomes, risk passes down generations. And this damage isn’t going away any time soon. Even in the absence of discrimination, Nancy Krieger argues that populations “would continue to exhibit persistent disparities reflecting prior inequities.”

How does this work exactly? We’re probably aware of genetic traits and social habits – desirable and undesirable – that we’ve inherited from our parents. And we probably agree that racism is often taught by parents and learned by children. But how does health risk from racism pass down generations?

In 2009, Howard University College of Medicine researchers proposed a conceptual model of how discrimination harms a child’s health. First, they divided the types of racial discrimination into microsystem (individual) and macrosystem (structural) exposures. Second, they argued that both types click on psychological and biological responses. These responses cause mental distress and changes in allostatic load (which means, for example, a person’s immune response decreases and blood pressure increases). Ultimately, these changes result in poor health and create health disparities.

But what’s especially striking is how the impact of discrimination flows from the parent to the child. In the Howard model, with the exception of racist bullying, both the microsystem and macrosystem exposures focus on parental experience. On the micro level, parents may suffer from harassment. On the macro level, they may also suffer from discrimination in housing, employment, and healthcare. These sources are not always neatly split. Personal and institutional discrimination can be two dimensions of the same event – consider a leasing agent who discriminates against an apartment applicant. No matter the source, the health outcome may be the same.

“The Art of RE-Membering How to Be Human.” Lola Audu. CC BY 2.0, 2012.

To see the effects of discrimination, sometimes we need to follow its path downstream. We can imagine many scenarios. For example, we know minorities are disproportionately stopped, searched, and arrested for non-violent drug offenses. This can eliminate their ability to gain student loans and access to education, which can limit their employment opportunities. When this person becomes a parent, this can frustrate their ability to provide quality education, housing, and healthcare. As they attempt to provide in a system that delivers anything but opportunity, discrimination may also drain their emotional resources for parenting and shape their involvement with social systems that hurt them before.

This tells us that the effects of racism are often not instant. Racism is not an on/off switch for health. Perhaps what we need is a model that accounts for how events unfold over time and link lives together.

In a 2012 paper in the American Journal of Public Health, Gilbert Gee and colleagues proposed a life course perspective to think about racism and health inequities. How racism impacts health depends on a person’s age. Among other things, a life course model accounts for sensitive periods, when social stressors exert the most impact on a person’s future. One of the most sensitive periods, as one might expect, is early childhood.

But the reason may be less obvious. As we age, we enter (and exit) social systems. Gee and colleagues point out that these social systems – for example, education, criminal justice, and labor – drive health inequities. But the lives of parents and children are linked. So, when a parent is discriminated against in one social system, such as labor, it can affect a child during a critical development stage. In fact, research shows that early childhood poverty has long term effects on that child’s achievements, health, and income as an adult. The life course perspective shows how the effects of discrimination proliferate, are latent, and link lives together.

Discrimination creates fault lines across generations. Usually, when we think of inheritance, we think about genes, or social habits, or wealth. And these, no doubt, are important factors for health. But there’s more. Discrimination works to constrain life chances. Sometimes the actual event occurs before the child is born. Even if we eliminate the micro and macro level sources of discrimination today, we are still behind – and we’ve got a lot of catching up to do.

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