Author: Jason Silverstein

The Food Stamp Vaccine

What if there were a vaccine against the harmful effects of hunger? According to researchers at Children’s HealthWatch, there is. But these vaccines aren’t shots or sprays. They’re food stamps.

Unlike other vaccines, these certainly aren’t a high priority for many lawmakers. In September, the House of Representatives voted for $40 billion in cuts over ten years to the Supplemental Nutrition Assistance Program (SNAP). Regardless, on November 1, the 13% increase to SNAP benefits from the 2009 stimulus expires. This means a family of three will have $29 less per month – and live on only $1.40 per person per meal.

This is dangerous. Like a vaccine, food stamps protect young children against immediate and future disease. “The right immunizations in the right doses at the right time save untold health and education dollars, not to mention personal anguish and pain,” Children’s HealthWatch wrote in their 2012 report, The SNAP Vaccine. “Hunger and food insecurity in the U.S. also endanger the bodies and brains of millions of children.”

Hunger cracks open a fault line in a child’s life. Like a vaccine, food stamps are especially critical in a child’s first years. Without enough food, kids are at an increased risk for delays in motor skills and cognitive deficits.

When kids don’t get this vaccine, they don’t only suffer damage to their bodies. They also suffer damage to their life chances. By third grade, kids who went hungry in kindergarten pay, on average, a 13 percent penalty in reading and math scores. By age 11, food-insufficient children are more likely to have lower test scores, have repeated a grade, been suspended, and had trouble making friends.

There’s little mystery why. But researchers at Cornell and the National Center for Health Statistics wanted to dig deeper. They analyzed data from the third National Health and Nutrition Examination Survey. Kids from food-insufficient families had more stomachaches, headaches, and colds. They were generally in poorer health. And they didn’t deal with food-insufficiency in a vacuum. They also dealt with the environmental risks of poverty.

"Family Dinner.” US Department of Agriculture. CC BY 2.0, 2012.

“Family Dinner.” US Department of Agriculture. CC BY 2.0, 2012.

Children’s HealthWatch piles on additional evidence – and provides a stark forecast for what may happen because of the cuts to SNAP. They analyzed the health records of 17,000 young children. These children were admitted to an emergency room or a hospital between 2004 and 2010. The researchers compared the health of children who received food stamps with children who did not. Kids who did not receive food stamps were more likely to be underweight and suffer from developmental delays. It gets worse. The kids who did not receive food stamps, according to Children’s HealthWatch, were likely eligible for them. Their malnutrition and developmental issues were preventable.

Like most vaccines, food stamps are especially important for our most vulnerable citizens: children and the elderly. But the new House bill seeks to slash the funding for food stamps in half. These cuts don’t only threaten their health. They also strangely take shots at their character.

The House bill tries to criminalize populations who need food stamps, stacking drug testing onto the requirements for food. Of course, we know that drug testing of welfare recipients is an absurd exercise. Arizona, for example, tested nearly 87,000 people over three years. They caught one person and saved $560. Virginia, more wisely, abandoned their welfare drug testing program, once they realized it would cost them more than six times what they’d save. Still, it presents us with a thought experiment: would we refuse a MMR shot for the child of a drug user? If food stamps provide vaccine-like protection against disease, don’t we have a moral obligation to provide it, regardless of a parent’s recreational drug habit?

Budgets are not only fiscal plans. They are moral ones. They document what – and who – is valuable. Food stamps prevent health problems and promote healthy lives for poor children. Why should their lives be any less nurtured?

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How the War on Drugs Punishes Those Who Suffer

The disparity in available pain medicine between rich and poor countries is the most pronounced health inequity in the world, says Amir Attaran, Associate Professor and Canada Research Chair in Law, Population Health and Global Development Policy at the University of Ottawa.

In their 2012 PLOS Medicine paper, “The Inadequate Treatment of Pain: Collateral Damage from the War on Drugs,” Attaran and Ottawa colleague Jason Nickerson explain that the International Narcotics Control Board (INCB) binds countries to pain medicine quotas. These quotas vary tremendously. But they don’t vary by need. They vary by income.

“There was a five thousand fold difference in per capita availability of pain meds between the countries that were the best off and the countries that were the worst off. I cannot think of another disparity in global health that has a five thousand fold difference,” Attaran said.

This hurts the people who need pain medicine the most. The World Health Organization estimates that 83% of the world’s population – 5.5 billion people – have “low to non-existent” access to pain medicine for moderate to severe pain. This includes over 1 million end-stage HIV/AIDS patients and 5.5 million terminal cancer patients.

Figure: Grams of morphine per capita versus gross national income.” Jason W. Nickerson and Amir Attaran. from "The Inadequate Treatment of Pain: Collateral Damage from the War on Drugs."

Figure: Grams of morphine per capita versus gross national income.” Jason W. Nickerson and Amir Attaran. from “The Inadequate Treatment of Pain: Collateral Damage from the War on Drugs.”

Though nearly 50% of the world’s cancer patients and 90% of the world’s HIV/AIDS patients live in low-to-middle income countries, they only receive 6% of the world’s morphine supply. North America and Europe, on the other hand, receive close to 89% of the world’s morphine.

When the time comes to fill out the paperwork, this inadequate supply serves as a baseline estimate – and makes inequity the country’s normal. Attaran and Nickerson write,

These estimates are based on the country’s own prediction of its pain treatment needs for the projected year, frequently using data on the number of treatments consumed in the previous year. Thus, a country that consumed low amounts of drugs in previous years can become trapped in a cycle of reduced access in subsequent years, divorced from any epidemiological measure of actual clinical need.

The INCB implements the two UN treaties on drugs, the 1961 Single Convention on Narcotic Drugs and the 1971 Convention on Psychotropic Substances. Their mandate should put them in a bind. On one hand, they are mandated to control these substances in the war on the drugs. On the other hand, they are mandated to promote them in the war on pain. But preventing a societal bad (substance abuse) – at least in poor countries – has been far more important than enabling a societal good (pain relief).

“To some extent, licit use of narcotics will always open the door and invite some illicit use. I mean, I think that’s inevitable,” Attaran said. “The question is, does one accept that risk of illicit use as a societal adverse effect of the licit clinical benefit that can be gained by appropriate access to those medicines?”

Though Attaran and Nickerson are concerned in this paper with global health disparities, we also see this ethical trade in the US. In 2010, the Senate held a special listening session, “The War on Drugs Meets the War on Pain: Nursing Home Patients Caught in the Crossfire.” In the testimony, we meet an 86 year old woman with intense pain from spinal surgery whose Percocet couldn’t be filled. Her pain became so unbearable that she required a second hospitalization in order to get her pain medicine, before returning to the nursing home. We also meet an end-stage HIV patient who couldn’t receive narcotics for 18 hours because his electronic records lacked a signature. Even in a country where supply is relatively great, the need of people in pain goes unmet.

DEA measures to crackdown on substance abuse has had the predictable effect of a crackdown on people in pain. This isn’t getting better. In January, an FDA committee voted to move hydrocodone combination medicine into the restrictive schedule 2 category of controlled substances. Here’s what this means. A nurse at a long-term care facility cannot communicate a schedule 2 prescription to a pharmacy, which means a patient must wait until she is seen by a doctor. Like the 86 year old woman we met earlier, this could mean a second hospitalization, simply for pain management.

These harsh rules might make sense, if they worked to fight addiction. But they don’t. Not only have drug laws not weakened the market for illegal drugs, as Evan Wood and colleagues point out, they’ve actually strengthened it: drug prices have fallen, purity has increased, and supply has grown. Countries such as Russia, China, and US have some of the harshest drug laws and the highest number of injection drug users. Meanwhile, on global and local scales, the poor and elderly are punished in vain.

Attaran sees this problem getting worse. “This will grow in significance as noncommunicable diseases do. Most communicable diseases kill you really quickly and without a lot of pain. HIV/AIDS being the exception, right? You’re not going to have prolonged, serious pain if you get malaria. On the other hand, if you get cancer, count on it. As NCDs grow in prominence, this will be a bigger deal. And not just fatal NCDs, but ones that are simply morbidity causing, such as arthritis, this will be a bigger deal.”

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The Gun Violence Epidemic

Violence breaks down communities. But, often, these communities are already broken down by poverty, joblessness, and inequality. When violence breaks out, people – and businesses – don’t want to move in. That means there are more school closings, more foreclosures, and fewer options for lower-income youth. Violence creates the conditions that make it thrive. Or maybe it’s the other way around. It’s hard to tell where it started. But some people have been trying to figure out how to make it stop.

“Violence is a crime issue, it is a social problem, it is a human rights problem, it is also a public health problem,” said James Mercy, the Special Advisor for Global Activities in the Division of Violence Protection at the CDC.

Now it’s obvious why violence is a public health problem. But it hasn’t always been this way. Mercy and Linda Dahlberg give us the play-by-play in a 2009 report for the CDC. There are two main reasons. First, there was a dramatic burst in homicide and suicide rates in the 1980s. Second, we started to accept behavioral factors as targets in disease prevention.

“There’s no one solution,” Mercy said. “These types of problems, like heart disease, require interventions on multiple levels. In general, what seems to be most effective, are early-type interventions. Interventions around parenting, and the environments that children are in.”

There are also interventions that try to stop violence as it starts. This has become known as violence interruption, which came out of Gary Slutkin’s anti-violence initiative, CeaseFire (now known as Cure Violence). Founded in the West Garfield neighborhood of Chicago in 1995, the project uses outreach workers, often former gang members, to conduct mediation. In 2011, Steve James filmed a documentary on the program, The Interrupters.

“Gun violence in particular acts very much like a social contagion. It spreads like a virus,” said Daniel Webster, Director of the Center for Gun Policy and Research at Johns Hopkins. “It spreads over time and place and among social networks, just as a virus might. So Slutkin thought about what was effective in controlling HIV and TB and other infectious diseases. A lot of times it boils down to what is the most proximate key behavior.”

Violence interruption hasn’t only been used in Chicago. By 2012, the Robert Wood Johnson Foundation set up 15 more sites to implement violence interruption. Webster and Jennifer Whitehill brought the program to Baltimore’s violent neighborhoods as Safe Streets. They reported much success: “5.4 fewer homicide incidents and 34.6 fewer nonfatal shooting incidents, on average, across all program sites during 112 months of observation.” They also seemed to break the social support for violence as a solution.

“What these violence interrupters do is help people realize that the social norms have not been serving them or their communities particularly well. They give people an excuse to walk away from situations they might otherwise feel like the social code is ‘I have to respond with violence’,” Webster said.

"Thou Shall Not Kill - Stop Killing - Stop Violence - Limousine.” Seth Anderson. CC BY 2.0, 2011.

“Thou Shall Not Kill – Stop Killing – Stop Violence – Limousine.” Seth Anderson. CC BY 2.0, 2011.

But where is the violence coming from? I spoke with Rebecca Levin, the Director of Strengthening Chicago’s Youth (SCY), to try to understand. Created by Lurie Children’s Hospital of Chicago, SCY brings together public and private stakeholders to tackle youth violence. They created a “Focus on Five” actions that everyone can take to prevent gun violence.

“One of the items on there is about access to firearms and gun violence prevention policy,” Levin said. “But you could get rid of every gun in Chicago, that would get rid of our gun violence problem. But that wouldn’t get rid of all our underlying issues and all the other pieces related to the gun violence issue.”

For Levin, the root cause of gun violence is related to structural violence.

“If you look at the cities that are experiencing more success with violence prevention, with cities with less success, slower declines are more segregated,” Levin explained. A recent New York Times report (“A Chicago Divided by Killings”) backs Levin up: “residents living near homicides in the last 12 years were much more likely to be black, earn less money and lack a college degree.”

Previously on this blog, I wrote about the health impact of racial residential segregation. Consider Chicago. We know Chicago remains one of the most segregated cities in the United States. We also know that we see dramatic differences in life expectancy, when we move from a predominantly white to a predominantly black neighborhood.

Segregation causes, as the sociologist William Julius Wilson might call it, an “accumulation of disadvantages.” Segregate a population and they get decreased access to resources, increased poverty and joblessness, and more constraints on their life chances. Concentrated poverty creates an environment for violence. But violence, also, creates more poverty: fewer businesses want to invest in an area, which depresses property values and decreases civil services, and keeps people disconnected from job networks. Gun violence is a public health problem that causes more public health problems.

“It is noteworthy how these conditions overlap. Substance abuse, violence, those are the particularly key ones that are quite concentrated in social disadvantage,” Webster said. “If you can reverse those determinants, you could stand to benefit not only with respect to violence but other health outcomes as well.”

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What Is the Health Impact of Fracking?

Does fracking impact health? It’s a question that some want to answer before projects begin. After all, we know pipelines have caused massive damage before. Since 1993, there have been 5,613 significant pipeline incidents that cut short 367 lives. Ten people were killed last year. In 2010, a pipeline in San Bruno, California, ruptured. The fire from that explosion destroyed 37 homes, damaged 18 others, and killed 8 people. Many more were injured.

But no one is quite sure what the overall health impact is – and it’s not getting any easier for researchers to find out.

Earlier this month, the New York Senate Majority Coalition blocked a vote on a fracking moratorium in the state. In March, the New York Assembly passed the moratorium. Now, it looks like the legislation may be doomed, since it must arrive on the Senate floor before their session ends on June 20.

"Anti-fracking demonstration outside New York Governor Cuomo's office.” Adam Welz/CREDO Action. CC BY 2.0, 2012.

“Anti-fracking demonstration outside New York Governor Cuomo’s office.” Adam Welz/CREDO Action. CC BY 2.0, 2012.

There’s reason to be concerned. Spectra Energy will complete its 16 mile pipeline from New Jersey to New York in November. This pipeline will pump 800 million cubic feet of hydrofracked gas below Manhattan’s West Village every day.

But what do we know about the public health impact of fracking? On May 30 and 31, the National Academy of Sciences hosted a workshop on “Risks of Unconventional Shale Gas Development.” In their presentation on the public health risks, John Adgate, Bernard Goldstein, and Lisa McKenzie reviewed the literature. In their abstract, they wrote:

In worker populations the most serious risks are job-related mortality from worksite or traffic accidents. Based on existing data from conventional hydrocarbon development industries the principal chronic morbidity concerns for shale gas workers are though to be silicosis and cancers associated with hydrocarbon exposures (e.g., leukemia) as well as respiratory and dermal diseases related to these exposures. People living near shale gas operations report noticeable odors and, in some cases, upper respiratory, neurological, and dermatological symptoms that they consider related to development and production activities.

Other presenters discussed the impact of fracking on water resources. Avner Vengosh of Duke University’s Nicholas School of the Environment discussed both the short and long term risks. In the short term, they worry about stray gas contamination and potential spills. In the long term, there are concerns about water shortage, pathways for gas and brine to flow into drinking water, improperly sealed or abandoned wells, and improper disposal of wastes.

“The industry brushes these impacts off. But there are far too many correlations, far too many stories of very serious and very scary health impacts. It’s an area where we know the impacts are happening and we need more information on how widespread they are,” said Katherine Nadeau, Water & Natural Resources Program Director of the Environmental Advocates of New York.

But some people argue that fracking can be done safely. In a review for Science, R.D. Vidic and colleagues argue that it is possible to “avoid an adverse environmental legacy.” The authors minimize the negative consequences. They cite “only one documented case of direct groundwater pollution.” Other incidents, they write, were “quickly mitigated.” With the proper water management, drilling, and cementing practices, the authors suggest that fracking can be safe.

"Natural Gas Fracking.” Daniel Foster. CC BY 2.0, 2013.

“Natural Gas Fracking.” Daniel Foster. CC BY 2.0, 2013.

Others aren’t so sure. “This is major industrial activity and major industrial activities carry major consequences. I don’t think there are blanket assertions that really fit. When something does go wrong, we see major consequences,” said Nadeau.

“It’s a very difficult question to answer with current information,” said Miriam Rotkin-Ellman, Staff Scientist at the Natural Resources Defense Council. “There’s a huge vacuum in information.”

This information deficit is convenient for some supporters of fracking. Here’s how this works. The collection of evidence is prevented. Then the lack of evidence is cited in support of their position.

See Elizabeth Ames Jones, a past chairman of the Texas Railroad Commission, who brushes off “the frightful accusations” because of their “precious little evidence.” Or a spokesman for Energy in Depth who cautions against “blaming impacts on the most convenient thing (i.e. hydraulic fracturing) without scientific evidence.”

But a fracking moratorium would allow the collection of scientific evidence. Now, it seems like it might not happen in New York. This would be bad news anywhere. However, this particular source of natural gas, the Marcellus Shale, seems particularly dangerous.

“There is considerable variation within, and among, the different shales. What in one area is a health risk may not be a health risk in another area,” said Rotkin-Ellman.

The Marcellus Shale seems to be especially hazardous, because of its radon concentration. Radon causes lung cancer. A report by Marvin Resnikoff, of the Radioactive Waste Management Associates, states that “wellhead concentrations in Marcellus shale are up to 70 times the average in natural gas wells throughout the U.S.”

Perhaps the most important question, then, is not, do we know the health impact of fracking? The better question is, why don’t we know the health impact – and why are some politicians standing in the way of finding out?

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

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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How Discrimination Links Lives Together

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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The Public Health Problem of Anti-LGBT Bullying

Bullying of LGBT teens is a serious public health problem. To address it, we must start with legislation to overhaul school environments. Only fourteen states specifically protect LGBT students from bullying. And there is no federal law. But two bills could change this – if Congress acts.

Bullying poses serious mental and physical health risks – and the risks are greatest for LGBT teens. They suffer from an increased risk of depression, anxiety, and suicide attempts. School doesn’t only feel unsafe – though that’s the experience of 71% of rural and 62% of suburban kids. School is unsafe for nearly one of five, who have been physically assaulted. When school feels and is unsafe, it’s the last place these kids want to be – and, when there, some of the smartest can’t excel.

Our schools do not protect them. But this could change in the 113th Congress. Two bills are expected to be reintroduced. Both bills amend existing law. First, the Safe Schools Improvement Act (SSIA) would amend the Safe and Drug-Free Schools and Communities Act. It would require federally-funded schools to prohibit bullying on the basis of sexual orientation and gender identity. It would also require states to report cases of bullying to the Department of Education. The second bill is the Student Non-Discrimination Act (SDNA). It is modeled on Title IX, which prohibits discrimination on the basis of sex. Likewise, the SDNA would prohibit discrimination on the basis of perceived sexual orientation and gender identity. But both bills have failed before.

“Loneliness.” Ktoine. CC BY 2.0, 2011.

There’s reason to believe legislation could help fix the public health problem. Not only do most states not protect LGBT students, but some states have statutes or policies that staff must “remain neutral on matters regarding sexual orientation.” But these neutrality policies are often only neutral in name. Recently, Tennessee’s ‘neutrality’ policy resurfaced. Commonly known as the “Don’t Say Gay” bill, the proposed bill would ban any discussion of homosexuality – except, in its latest incarnation, for teachers who must report suspected homosexuality to a student’s parents. Even though the bill’s official title is the “Classroom Protection Act,” it’s obvious that the bill would subject LGBT teens to increased stigma, social isolation, and eliminate safe pathways to report harassment.

Even when students have pathways to report, some remain silent out of fear. But it is not always a fear of retaliation by another student. It may be the fear of teachers, administrators, and officials who help create an anti-LGBT environment. In a law review article on finding a legislative solution for ‘bullycide’, Jason A. Wallace explains the reason students failed to report harassment was because a staggering “two-thirds of students hear[d] teachers and school staff make homophobic comments.” We know bullying is often the product of social isolation. But bullying is also the product of social immersion, which makes physical and emotional violence into a routine, often guaranteed by those who are trusted to ensure safety.

Can legislation really help? We already have some evidence that a positive social environment – and anti-bullying policies – reduces the health risk of anti-LGBT bullying. Mark L. Hatzenbuehler’s 2011 study in Pediatrics shows that a supportive social environment reduces suicide attempts by LGB teens. Hatzenbuehler created a novel index of social environment that included five measures: “(1) proportion of same-sex couples living in the counties; (2) proportion of Democrats living in the counties; (3) proportion of schools with gay-straight alliances; (4) proportion of schools with antibullying policies specifically protecting LGB students; and (5) proportion of schools with antidiscrimination policies that included sexual orientation.” Having surveyed 31,852 eleventh-grade students, Hatzenbuehler found that:

Lesbian, gay, and bisexual youth were significantly more likely to attempt suicide in the previous 12 months, compared with heterosexuals (21.5% vs 4.2%). Among lesbian, gay, and bisexual youth, the risk of attempting suicide was 20% greater in unsupportive environments compared to supportive environments. A more supportive social environment was significantly associated with fewer suicide attempts, controlling for sociodemographic variables and multiple risk factors for suicide attempts, including depressive symptoms, binge drinking, peer victimization, and physical abuse by an adult (odds ratio: 0.97 [95% confidence interval: 0.96–0.99]).

While this study doesn’t allow him to identify the precise mechanism, Hatzenbuehler emphasizes one connection. “One potential pathway is through increased exposure to status-based stressors,” Hatzenbuehler writes. Where are these stressors most highly reported? In states that deny LGB adults legal protections.

In response to the suicides of bullied teens, including Billy Lucas, Raymond Chase, Tyler Clementi, Ryan Halligan, Asher Brown, and Seth Walsh, Dan Savage and his husband Terry Miller launched the “It Gets Better” project in 2010. It is a breathtaking project – educational, inspirational, and an important public health intervention. But students shouldn’t have to bear the bad. Their lives should not be sacrificed in someone else’s rite of passage. And what others have heroically overcome does not need to become a part of growing up. The good news is that we can start to repair this public health problem by addressing the social environment of LGBT students. The bad news is that we must depend on Congress to act.

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Beyond Crime and Punishment


We have a problem, you know, and it’s only getting worse. It doesn’t strike us equally – it’s a problem that mostly affects young men, minorities, and people without high school diplomas. It’s worse in the US than anywhere else in the world – and five times as bad in the state of Louisiana than it is in Iran. Its survivors usually don’t make good advocates – not while they fight for employment, hold onto their families, and, in some states, lose the right to vote. The problem of mass incarceration is a problem some don’t want to address, because the felon class represents those who must have known they would trade for their crimes a piece of their lives. But the health risk of prison doesn’t end when their sentences do. In some cases, it has only just begun – and not just for them.

It is one of the great ironies of American society: prisoners are constitutionally guaranteed healthcare, but former prisoners are not. The prison health paradox is one dramatic way to think about the health disparities of impoverished minorities in the United States. In 2010, Evelyn Patterson found that “prison appears to be a healthier place than the typical environment of the nonincarcerated black male population.” Indeed, during incarceration, black-white mortality differences vanish. But once released, we see something else entirely. The mortality rate skyrockets. The deadliest time is the first two weeks after release, when former inmates have a 12.7 times higher risk of death than the general population and a 129 times higher risk of drug overdose.

One explanation is that prisoners are often returned to their old neighborhoods – and returned to their old risk factors for homicide and drug overdose. This cycling to and from prison has been called “coercive mobility,” as it concentrates people with fewer and fewer resources into smaller and smaller areas. But another explanation is poor transitional planning. For example, poor transitional planning for prisoners with mental illness translates into an excess risk of suicide within the first weeks that follow release. But this is not only a short term problem. Because there is a long term health problem that former prisoners face that is not infectious, mental, or violent: the problem of being former prisoners.

“Jail.” 826 Paranormal. CC BY 2.0, 2010.

Former prisoners pay a social penalty for incarceration – and it affects their health and their community. Former prisoners are doubly disadvantaged as they struggle for employment and they are eliminated from welfare. In a recent Annual Review of Public Health article, we learn that “a prison record eliminates eligibility for public assistance such as food stamps, public housing, and student loans.” A prison record also reduces the ability of former prisoners to find employment – especially employment that provides suitable health care coverage. Medicaid may not be an option for them, or at least not an easy one, since 90% of states withdraw Medicaid coverage once an inmate’s sentence begins. Not only does incarceration disrupt employment, which we know affects health status, but also marriage, which is another indicator of physical health. Marriage and employment are “two key tenets of adult health,” Michael Massoglia writes, which disproportionately impact African Americans.

In the Du Bois Review’s special issue on “Racial Inequality and Health,” three sociologists discuss the ‘spillover effect’ of incarceration. That is, parental incarceration harms children, especially those who live in areas highly concentrated with former prisoners. In her article, “Punishment Beyond the Offender,” Megan Comfort shows how children may be collateral damage in the exercise of the state’s punishment. Beyond the offender, their children become exposed to risky behaviors that decrease their life chances and increase their risk for mental illness. These children often end up funneled into the criminal justice system themselves.

The people most likely to suffer the negative health effects of incarceration are also the people most likely to already suffer from health disparities. Because African Americans are incarcerated at a rate higher than whites, racial health disparities are ultimately worsened by the effects of incarceration. In their Du Bois Review piece, Schnittker, Massolgia, and Uggen remind us that the mass in mass incarceration “is indeed ‘mass’ in the sense that it is now large enough to affect an entire demographic group.” In Michelle Alexander’s The New Jim Crow: Mass Incarceration in the Age of Color Blindness, we learn that more African American men are imprisoned today than enslaved in 1850. Incarceration does not only threaten the long-term health of individuals, but entire communities. In a justice system plagued by racial bias, incarceration threatens the health of an entire race.

Incarceration has become a feature of American life. We are told incarceration creates a barrier between the criminal class and innocent civilians. Incarceration keeps us safe. Why should we help those who threaten us? But inflicting social, civic, and political penalties on former prisoners does not reduce criminal behavior; it only encourages it. We should focus on strengthening transitional services to facilitate reintegration – in both our prisons and jails – and release the punitive grip on healthcare, welfare, housing, voting rights, and student loans. Or else we risk cementing health disparities in the name of a questionable justice.

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Race – and Place – Matters for Health

A child is born in the United States. How much information do you need to predict her future health? To predict if she will enjoy a healthy life? If she will die an early death?

One important piece of information is where she lives. And more specifically, if she lives in an area of racial residential segregation. In 2001, David R. Williams and Chiquita Collins called racial residential segregation “a fundamental cause” of health disparities. For some time researchers had known socioeconomic status (SES) was linked to health inequalities. But what they had not asked, Williams and Collins point out, was what causes racial disparities in SES. Building on a literature that began in 1950, when Alfred Yankauer found a link between infant mortality and segregation, Williams and Collins show how segregation limits socioeconomic mobility – and, thus, access to education and employment and, ultimately, health.

One way sociologists measure group success is by the ability to pass advantage on to the next generation. This is called an “accumulation of advantages.” But when we consider how segregation, and structural racism, bears on health outcomes, we see something else. Racism creates an accumulation of disadvantages. While the majority of poor people in this country are white, William Julius Wilson has shown that most of those poor whites live in areas of economic integration. Most poor black Americans, on the other hand, live in poor neighborhoods. Concentrated poverty has profound consequences. In When Work Disappears: The World of the New Urban Poor, Wilson demonstrates how concentrated poverty increases joblessness, which threatens social organization, which, in turn, deepens poverty.

The impact on health of racial residential segregation is devastating. A 2011 study attributed 176,000 deaths to segregation in 2000. Michael R. Kramer and Carol R. Hogue provide a comprehensive review of the negative health effects of segregation in their 2009 Epidemiologic Reviews piece. They cite studies on the association of segregation with fewer healthy food options, obesity, low birth weight, cardiovascular disease, tuberculosis, HIV, gonorrhea, and how racism “weathers” the immune and neuroendocrine systems.

“Freedom Marchers.” Keoni Cabral. CC BY 2.0, 2009.

There’s probably no better place in the United States to study the negative health effects of racial residential segregation than Chicago. And the Joint Center for Political and Economic Study did just that. Though segregation has decreased in Chicago since the middle of last century, it remains the most segregated city in the United States, according to the Manhattan Institute for Policy Research. In July 2012, the Joint Center for Political and Economic Study released a study on Cook County, which has a black-white Index of Dissimilarity of 80.8%. (Index of Dissimilarity is a measure of segregation, which is somewhat problematic because it focuses on only two groups. It means that 80.8% of black residents would have to move elsewhere in order to evenly distribute the population.)

The Joint Center’s report – “Place Matters for Health in Cook County: Ensuring Opportunities for Good Health for All” – is chilling. In 2007, the premature death rate for black residents was 445.9 per 100,000 – for whites, it was 179.5. In six of the seven Chicago neighborhoods with the lowest life expectancy, the African American population was greater than 93%. In six of the eight neighborhoods with the highest life expectancy, the African American population was less than 10%. Not only does the Joint Center report show the tremendous moral cost of racial disparities, but they also calculate a staggering financial loss: $1.24 trillion from lost tax revenue and productivity. What does the Joint Center recommend? They say we must track health inequalities, understand food retail access, stimulate health food retail, ensure workplace justice, and address persistent poverty through partnership with governmental agencies.

Racial residential segregation impacts socioeconomic status, which impacts what social systems a person enters or exits (such as the school system, the labor market, and the criminal justice system). These life chances, when limited or constrained, deeply affect health. As poverty increases, joblessness increases, social organization decreases, and negative health outcomes increase. Poor health further removes residents of segregated neighborhoods from the labor market and, thus, adds to an accumulating amount of disadvantages. As the Joint Center writes, understanding racial residential segregation – and the neighborhood conditions that burden its residents – allows us to “powerfully predict who is healthy, who is sick, and who lives longer.” It hopefully will also push us away from the Daniel Moynihan model of “black pathology,” which wrongly suggests that something at the core of black residents is responsible for the negative effects of segregation. Rather, we need to hone our interventions at structural pathologies. Because we shouldn’t be able to predict how soon a child will die based on where she lives, but, as it stands now, we too often can.

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