public health: myths and realities

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Daniel

Jordan,

PhD, ABPP

PUBLIC HEALTH MYTHS AND REALITIES:

International University

for Graduate Studies

July 2012

www.iugrad.edu.kn

© Daniel Jordan, PhD, ABPP, [email protected]

改善 © Daniel Jordan, PhD, ABPP, [email protected]

WHAT IS

PUBLIC

HEALTH?

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Starfish

Downstreamers

TWO PARABLES

A New Parable of the Downstreamers

Daniel Jordan, PhD, ABPP, [email protected]

Adapted and Revised From: Ardell, D. (1986). The Parable of the Downstreamers. High Level Wellness: An Alternative to Doctors, Drugs & Disease. Ten Speed Press. Berkeley, CA.

People Were Drowning!

Downstream villagers saw the first

drowning person in the river many

years ago, but they could offer little

help.

No one knew how to swim, so they

organized swim training.

Some even got certificates and

advanced degrees.

People Kept Drowning!

But more drowning people kept

floating down the river.

Sometimes it took hours to pull

dozens from the river, and then

only a few would survive.

Some drowners even jumped back

into the water and were swept

away.

People Kept Drowning!

The Downstreamers wrote a grant

to get specialized life saving

equipment.

They raised private funds to build a

waterside rescue facility.

Volunteers staffed it 24/7.

They finally got funds for paid staff.

But Things Just Got Worse!

The number of victims kept

increasing, so . . .

They analyzed specific patterns of

how people were floating down the

river, looked for specific eddies and

currents, then modified those water

flow patterns to reduce local risks

and improve the ability to respond

Finally Things Improved!

Outcomes research showed that

Downstreamers’ rescues increased

from 27.8% to 62.3% in 20 minutes

or less, 16.7% are saved in 7

minutes or less!

Downstreamers were very proud!

They wrote articles, attended

conferences, got awards

Downstreamers were Proud of Services and Supports . . .

New hospital at the edge of the river,

A flotilla of rescue boats ready,

Comprehensive plans for staffing

Highly trained and dedicated swimmers ready to risk their lives

Mental health counselors deal with trauma

Downstreamers are Proud of Services and Supports . . .

This has been good for the economy

A lot of “good people” have good paying jobs, they also feel productive and useful, fulfilled

Downstreamers hold an awards banquet every year

They get government honors and grants, newspaper articles

. . . But Some Downstreamers Disagree

They believe that people need to take care of themselves

They’re upset with having to help people “who won’t help themselves” by learning to swim

They say other needs go unmet, and they are being taxed to death for people who aren't Downstreamers anyway, send them back where they came from

No new taxes!!!!!!

Both Groups Overlook Some Key Questions.

Someone finally asks . . .

What’s Going on Upstream??!!

Who Keeps Throwing People in the River??!!

Are systemic causes getting people in trouble?

And then in the most Radical Act of All . . .

. . . a couple of Downstreamers Shift

their focus: They ask why drowning people are in the river at

all

Even Worse: They decide to go

upstream to find out who is throwing people in the river, and even

worse than that: They decide to do

something about it.

Many Downstreamers Get Upset with the Questioners

Some complain that the people going upstream are too radical. If people are drowning, it’s their own fault.

Others worry that trying to change things will mean people drowning right now won’t get helped. Their work is important.

But: What if drowning people stopped floating down the river?

Many Downstreamers Say These People are too

Radical The couple are told they should keep

working “inside the system,” that's how change really happens. Don’t make waves, even more people will drown.

They're told not to make too much of a fuss, it isn't polite, and funders might decide to stop giving grants.

The couple say they're going anyway and start to pack.

The Downstreamers Act!

Downstreamers hold a meeting and decide to ostracize the couple.

The couple load their car to go upstream.

Downstreamers rush the couple, grab them, and throw them into the river.

They float away.

Problem solved!

And Everyone Upstream and Downstream Lived

Happily Ever After

Except for the drowning people of course, and those who wanted

to reduce the need.

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A shift in focus: The community,

society

Serve individuals for community

welfare

Community is the client

Social model not medical model

Physical, mental, and emotional

Context Matters

What is the responsibility of the

primary care provider?

PUBLIC HEALTH IS . . .

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If we just keep helping people at

the individual level, the needs

will be the same or worse 10, 20,

100 years from now.

HYPOTHESIS I

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The degree, extent or rate of

inequality and discrimnination

are the two most consistent

predictors of social problems

HYPOTHESIS II

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Elitism is efficient (and efficiency is good)

Exclusion is necessary

Prejudice is natural

Greed is good

Despair is inevitable, and is the goal to assure conformity

[These conditions are sustainable]

SIX TENETS THAT

MAINTAIN INEQUALITY

Derived from Danny Dorling, Injustice: why social inequality persists

http://sasi.group.shef.ac.uk/presentations/injustice/

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Pursue social change, with and for vulnerable and oppressed individuals and groups: Confront poverty, unemployment, discrimination, and other forms of injustice

Not practice, condone, facilitate, or collaborate with any form of discrimination based on race, ethnicity, national origin, color, sex, sexual orientation, age, marital status, political belief, religion, or mental or physical disability

NASW ETHICAL RESPONSIBILITY: SOCIAL JUSTICE & DISCRIMINATION

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Promote general welfare of society, local to global levels, development of people, communities, and environments

Advocate living conditions that fulfill human needs

Promote social, economic, political, and cultural values and institutions to realize social justice

NASW ETHICAL RESPONSIBILITY:

TO BROADER SOCIETY

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Engage in social and political action to ensure that all people have equal access to resources, employment, services, and opportunities to meet basic human needs and develop fully

Be aware of impact of politics on practice

Advocate for changes in policy and laws to improve conditions to meet basic human needs and promote social justice


SOCIAL & POLITICAL ACTION

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Act to expand choice and opportunity for all, especially vulnerable, disadvantaged, oppressed, and exploited people and groups

Promote respect for cultural and social diversity nationally and globally

Promote policies and practices that show respect for difference, support expansion of cultural knowledge and resources



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Advocate cultural competence, and policies

that safeguard rights of and confirm equity

and social justice for all people



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Act to prevent and eliminate domination of, exploitation of, and discrimination against any person, group, or class based on race, ethnicity, national origin, color, sex, sexual orientation, age, marital status, political belief, religion, or mental or physical disability


GLOBAL SOCIAL JUSTICE

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Public health is about helping people

find ways to lead healthier lives, in every

sense.

Public health’s roots tap into social work

activism about the betterment of society.

Public health standards are divided into

three core functions further broken down

into ten essential services

FUNDAMENTAL CONCEPT

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THREE CORE

FUNCTIONS

TEN

ESSENTIAL

PUBLIC

HEALTH

SERVICES

SYSTEM

MANAGEMENT

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More

Citizen Control

Empowerment

Delegated Power

Partnership

Education

Placation

Consultation

Informing

Therapy

Manipulation

Less TE

N L

EV

EL

S O

F

CH

AN

GE

Modified from, Arnstein, Sherry R. Eight

Rungs on the Ladder of Citizen

Participation. In Cahn, Edgar S. and

Passet, Barry A, eds. Citizen

Participation: Effecting Community

Change. New York, Praeger, 1971., p. 70.

Lower steps can

be used to

influence higher

steps, e.g., therapy

can be a tool to

raise awareness to

educate and

empower people.


Role of the

change agent

PRAXIS &

CRITICAL

COMMUNITY

EDUCATION:

EMANCIPATION FOR

EMPOWERMENT

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cti

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II

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From: Tones. K.

(2002) Reveil le

for Radicals!

The paramount

purpose of

health

education.

Oxford J.

PRAXIS &

CRITICAL

COMMUNITY

EDUCATION:

EMANCIPA-

TION FOR

EMPOWER-

MENT

Community worker seeks: • To gain acceptance

by community • Listens and

empathises • Encourages

expression of ideas

Identify root causes of social problems, e.g.,environmental, social, economic, political

Success breeds success. New needs identified by community members. They develop skills and gain confidence to undertake new tasks.

Praxis: Stage of

Reflection and Action:

Solutions identified,

discussed, and acted on

Community Action

Community Self-

Advocacy

Identify

Community

Leaders

Provide

Supports

Develop

Skills

Establish

Community

Coalitions

Identify

Felt

Needs

Community worker raises awareness of health and social issues, e.g., help community members develop video voice maps of environ-mental conditions, public speaking exercises

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PUBLIC HEALTH AND

COMMUNITY TRANSFORMATION

Show up, shut up, and

Listen In other words,

therapists have a lot to offer efforts to

change the contexts that cause social problems

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WHAT WE HAVE TO OFFER THE

COMMUNITY

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Exposure to toxins, pesticides, poisons

Air quality: diesel exhaust, carbon monoxide

Noise pollution (leads to decreased academic

performance)

Water pollution

Perverse incentives : Fast food

would not be cheaper without

tax incentives to produce

those types of products

SERIOUS INCREASES IN DISEASES AND

ILLNESSES

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FAST FOOD NATION, FAST FOOD WORLD

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Since 1991 US obesity rates increased

74%.

HERE’S WHERE WE GOT OFF COURSE

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Average BMI = 35 (obesity = height to weight ratio >30)

NAURU: MOST OBESE NATION ON EARTH

95% OBESITY

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CONSIDER THE MOST OBESE

NATION ON EARTH


PUBLIC HEALTH

AND INEQUALITY

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Millions, perhaps billions have been spent

on obesity and diabetes reduction and

treatment.

Have the numerous campaigns to reduce

the rates of obesity and diabetes been

effective?

Time period: 1985-2010 (Note: the CDC

changed its reporting methods in 1995)

HEALTH DATA STATISTICS: PART ONE

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Hypothesis: The greater the degree of

inequality in a society the higher the levels of

virtually every type of social problem,

including health problems.

Sources

Wilkinson and Pickett. The Spirit Level: Why Greater

Equality Makes Society Stronger http://www.equalitytrust.org.uk/

The State of Working America Economic Policy Institute: Working Group on Extreme Inequality

http://www.stateofworkingamerica.org/

http://extremeinequality.org/

20 Facts About US Inequality Everyone Should Know http://www.stanford.edu/group/scspi/cgi -bin/facts.php

HEALTH PATTERNS

http://www.equalitytrust.org.uk/

http://www.equalitytrust.org.uk/




Level of income disparity [inequality] in the study was the difference between the upper 20% and the lowest 20%.

Inequality can be low one of two ways: Everyone is relatively rich or Everyone is relatively poor

Examples:

Arkansas: Low inequality, low overall income

New Hampshire: Low inequality, high overall income

Correlation is not causation, but . . . When a hypothesis can be formed, and literally dozens of measures

all point in the same direction, a case begins to emerge that two factors that correlate consistently are likely to have a causal relationship.

WORKING DEFINITIONS


CDC DATA: OBESITY AND

DIABETES

Dri

ll D

ow

n E

xam

ple

Case Study:

Trends in Diagnosed Obesity

and Diabetes

CDC’s Division of Diabetes Translation.

November, 2011

National Diabetes Surveillance System:

http://www.cdc.gov/diabetes/statistics

http://www.cdc.gov/diabetes/statistics

Obesity Trends* Among U.S. Adults BRFSS, 1985

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% Note the Percentage Scale



No Data <10% 10%–14% 15%–19% Note the Percentage Scale

Age -Adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults

Note the Percentage Scale: 14% was the original high

Age -Adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults


Growing inequality will result in increasing

rates of disease and illness

Rich developed societies have reached a

turning point in sustainability

Politics needs to become about the quality of

social relations and how we can develop

harmonious and sustainable societies.

Inequality predicts disease and illness

Focusing on individual behavior offers little

opportunity for change.

CONCLUSIONS


In brief: two main ways of reducing

income inequality

smaller differences in pay before tax

(e.g., Japan)

redistribution through taxes and benefits

(e.g., Sweden)

Economic and Political Democracy are

both necessary to improve health (US

and UK have neither right now)

CONCLUSIONS


Trust among people, and quality of life,

would go up 75%

Mental Illness and Obesity would drop by

65%

Teen births would be cut in half

Prison populations could drop by half

People would live longer and could work

two weeks less a year as well. Etc. . . . .

WHAT IF WE REDUCED INEQUALITY?


Increasing equality is good for everyone,

the rich included.

Life gets better for all: Remember,

quality of life is NOT related to income or

wealth within a society.

The rich may think they wind up better

off, but in the end they lose as well.

WHAT ABOUT THE RICH?


Dis

cu

ssio

n ARE WE

KILLING OUR

KIDS?

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WHAT’S THE BIG DEAL?

• In 1974 The Lancet identified obesity as “the

most important nutritional disease in the

affluent countries of the world.” • Infant and adult obesity [editorial]. Lancet 1974; i:17-18.

• What happened since then? We got fatter.

• Worldwide, we’re dying at higher rates and

nations are becoming obese.

• It’s a syndemic: Obesity, diabetes, asthma,

other related diseases are tied together.

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A NUMBER OF NEW YORKERS ARE UPSET BY MAYOR

BLOOMBERG’S SODA BAN, SAYING THAT IT IS A

CHANGE THAT WILL DRAMATICALLY EFFECT THEIR

LIFEST YLE.

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ABOUT “IT’S JUST

ONE SODA

x 365 days/year =

15 pounds of body fat

So-called “juice drinks” and “power drinks” are just as bad.

They all rot your teeth.

Half of Americans’ calories come from soda. Half!

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ABOUT RESTAURANTS

• A typical restaurant portion size is two to

three times more than servings should be.

• We’ve been conned into measuring quality of

food in terms of quantity.

• We get far more saturated

fat and far fewer nutrients

than we should. We’re

starving while becoming

obese.

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ABOUT RESTAURANTS

• Kids get hit the hardest: They get twice as

many calories in restaurant meals than they

need.

• This simple fact yields a population of kids

that is amazingly obese, will have lifelong

health problems, and will die younger than

they should.

• Our marketing system is killing our kids, and

we’re letting it happen.

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Traditional Focus Transformative Focus

Deficits-based

Reactive

Individual & Family

Professional-driven

Strengths-based

Primary Prevention

Empowerment

Community Conditions

“SPEC” MODEL:

ISAAC PRILILTENSKY

Http://people.Vanderbilt.edu/~isaac.prilleltensky

Role shift: From “expert helpers” to “critical change agents”

Focus shift: From individual to community (context)

Power shift: From “providers” to community members

Locus of control shift: From victim to empowered actor

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No. If they did, we would see successes.

“A trap we must avoid, set by the food industry [is] the belief that education is the answer to nutrition problems.

The ostensible rationale is that people do not understand nutrition, that educating them will drive up demand for healthier foods, and that the industry will be happy to meet that demand.

The hidden rationale is that such programs will have little impact, allowing industry to do business as usual. I can see industry executives jump with glee each time government officials point to education as the answer .” Kelly D. Brownel l . http:/ /www.lat imes.com/news/opinion/ la -op-dustup19sep19,0,1026838.story

DO OUR CURRENT HEALTH SYSTEMS

WORK?

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1. education has weak effects, if any;

2. it drains resources;

3. it makes industry seem on the side of consumers; and

4. it bolsters industry's hope that government will allow it to self-regulate while government agencies sit on the sidelines.

5. It is the “perfect” script for public health failure.

• Ke l l y D . B rowne l l . h t t p : / /www. la t imes . com/news/op in ion / l a -op-dus tup19sep19 ,0 ,1026838 .s to r y

RESULTS OF HEALTH EDUCATION

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ABOUT INDIVIDUAL BEHAVIOR

This epidemic is about more than just individual behavior.

Analyzing only individual behavior, assigning blame just to each individual does not explain the stunning change in the pattern of behavior across individuals.

Something more than just “individual responsibility” is going on.

(But that doesn’t let individuals off the hook!)

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So why does the US continue spend any money

at all on health information and education,

obesity prevention, healthy lifestyles, etc.,

when it clearly does not work?

If a similar pattern were experienced in any

domain – private business, government, non-

profit – what would you advise be done?

Follow the money: Who benefits from these

realities?

The Point: You have to dig deeper.

QUESTIONS

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CONSIDER

“If people want to drink 24 ounces of soda, it’s their choice, and nobody else’s business.”

Does social, economic, political context have an impact on individual behavior?

Are we “free” in some abstract way or does the context in which we live impact our choices?

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Brainstorming Context: Forget everything you

know about health, healthcare, mental health,

substance abuse, wellness, systems and

programs.

Using the core assumption: If you were free to

spend a health budget however you could,

what would you do?

“CLEAN SHEET” EXERCISE

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If we were to create a health system from scratch

today, how would we organize ourselves and allocate

resources, and what would be our community

priorities?

Work in small groups and develop clean sheet

systems of care. Brainstorm wild ideas as well as

practical.

Choose a policy domain(s) of interest to your group.

You can focus on real agencies, your own

communities, local entities, state or national policy,

your choice.

“CLEAN SHEET” EXERCISE

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Try to develop something that you could work toward

in your own community.

How would you design your approach to developing

your plan?

Who would you talk to?

What procedures would you use to implement your

plan?

How would you promote it?

What community -level indicators would you

measure?

CLEAN SHEET EXERCISE

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If we keep doing things the way we do them

right now, 50 years from (assuming the world

hasn’t imploded) the next generation will be

doing exactly the same things we’re doing

now.

Only the need will be even greater.

The more an intervention engages power

equalization, the more transformative it will

be (Isaac Prilitensky)

CORE ASSUPTION:

CONTEXT MATTERS

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Small group presentations.

What are the implications of using the NASW

standards and to reform the helping

professions, health care plans in this case?

15 minute small groups, design a broad

intervention strategy.

DISCUSSION

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Bunker JP, Frazier HS, Mostel ler F. Improv ing health: measuring ef fects of medical care . Mi lbank Quar ter ly 1994;72:225 -58.

Bolen JR, Sleet DA , Chorba T, et a l . Overview of ef for ts to prevent motor vehicle - related in jury. In : Prevent ion of motor vehic le -related in jur ies: a compendium of ar t ic les from the Morbidi ty and Mortal i ty Weekly Repor t , 1985 -1996. At lanta, Georgia: US Depar tment of Heal th and Human Serv ices, Centers for Disease Control and Prevention, Nat ional Center for In jury Prevent ion and Control , 1997.

Hoyer t DL, Kochanek KD, Murphy SL. Deaths: f inal data for 1997. Hyattsvi l le , Maryland: US Depar tment of Heal th and Human Serv ices, CDC, Nat ional Center for Heal th Stat ist ics, 1999. (Nat ional v i ta l s tat ist ics repor t ; vol 47, no.20) .

CDC. Fatal occupat ional in jur ies - - Uni ted States , 1980-1994. MMWR 1998;47:297-302.

Anonymous. The s ixth repor t of the Joint Nat ional Committee on Prevent ion, Detect ion, Evaluat ion, and Treatment of High Blood Pressure . Arch Intern Med 1997;157:2413-46.

Burt BA , Eklund SA . Dent istr y, dental pract ice , and the community. Phi ladelphia , Pennsylvania: WB Saunders Company, 1999:204 -20.

Publ ic Heal th Serv ice. For a healthy nat ion: returns on investment in publ ic health . At lanta, Georgia : US Depar tment of Heal th and Human Serv ices, Publ ic Heal th Serv ice, Of f ice of Disease Prevent ion and Health Promotion and CDC, 1994.

ADDITIONAL REFERENCES



CONTACT FOR MORE INFORMATION

About this presentation:

Daniel Jordan, PhD, ABPP at

[email protected]

About the International University for

Graduate Studies graduate

programs:

www.iugrad.edu.kn

public health: myths and realities

Lifestyle