90210: Does ZIP code Affect Health?

Perhaps it is obvious to non-physicians that medical care accounts for a small proportion of peoples' overall health. Education and income are two of the strongest predictors of good health. As James Marks writes in a blog for the Huffington Post:

"College graduates can expect to live five years longer than those who do not complete high school...and people who are poor are 3x more likely to suffer physical limitations from a chronic illness."

These findings extend to other diseases such as diabetes, heart disease, and cancer.

So why is there still such emphasis on personal responsibility for poor health? Where we work, our social networks, and the communities we live in have more to do with our health (physical and mental) than the two hours a year that we spend in the doctor's office.

I applaud Marks for being bold and stating the obvious (for those of us social determinants folks out there...)

"As we consider health reform in 2009 let's think about the neighborhoods and towns in which we all live and ask ourselves: What are the barriers standing in the way to better health?"

We've learned our lesson from crash-diets and "good intention" gimmicks. It is not enough to try and be healthy (...I tried really hard to not eat that other half of the chocolate chip cookie this afternoon). We need to create environments where healthy living is normative, where it is expensive and cumbersome to buy unhealthy snacks and to sit on the couch or in a chair all day long. These changes involve community changes. It involves caring for the collective rather than blaming the individual. 

For example, it took compromise to create smoke-free public spaces that now exist all around the country. Now, we should slowly, but surely, look to create healthy environments in other ways. Those who oppose these efforts often don't realize that healthy environments create opportunities, they don't diminish them. The green movement hasn't stifled industry, it has given it a chance to innovate and progress into a new era. 

Let's take a cue from history and move forward with health reform. Rather than relying on medical-model and health-care driven solutions, let us first consider community and environment. Then we may find ourselves on the path to population-based health and wellness.

Religion & Health: a brief reflection

Should religious organizations be included in public health efforts to promote sexual and reproductive health in developing countries? This question was recently posed in one of my classes while discussing the links between adolescent religiosity and sexual behavior and HIV prevention in Ghana.

The association between religion and sexual behavior and health is complex. On one hand, religion can help people develop a moral code that promotes healthy sexual behavior by creating norms that premarital sex, multiple partnering, and infidelity are sins that are to be avoided. Religion can also create social networks that facilitate resource sharing and create social support to promote health.

On the other hand, religious values can conflict with scientific evidence showing that condom use can prevent disease transmission and that the pill can prevent pregnancy. Religious leaders can withhold information on how to prevent STI/HIV and unplanned pregnancy by preaching that "abstinence is the only way" -- when we know that it is not. It may be the BEST way -- but it is misleading to say it is on the only way.

The role of religion and faith-based organizations in promoting public health activities is quite controversial. Religious institutions have long been charitable service providers to poor, vulnerable populations. I think this work must and should continue. However, a class discussion spurred a few thoughts (or questions) on the topic that I thought were relevant.

1. How does religion influence health? Is it spirituality (believing in something greater than yourself)? Is it the community and social support brought about by being religious?
2. What is the difference between religion promoting "behavioral control" and religion promoting freedom to act in ways that result in greater self-control?
3. Does public health miss out on opportunities to reach a critical mass when it does not engage with faith-based organizations? (in other words: are there people who might only receive health communication information through religious leaders?)

It seems to me that collaboration with faith-based organizations is warranted in certain contexts, especially where religious affiliation and engagement is high. Many churches (note: not only churches, but also other religiously-affiliated institutions) around the world are engaged with HIV/AIDS-related care and many more are teaching their congregations about safe sex and sexuality. I love to see faith-based organizations offering holistic care and opening their doors to all people, no matter what their religious beliefs.

I also think that there are many circumstances where religious institutions are not reaching the poor and most vulnerable. Where this happens, public health professionals must communicate their health messages through other governmental or private organizations.

What do you think about the role of religion in public health? Are partnerships with faith-based organizations a good idea?

Next Steps: We must think critically about the opportunities and limitations of working with faith-based organizations in public health; however, we also must not discount their influence and authority in communities that we serve.

Respect for Others: A Universal Principle

The gender-neutrality of the need for respect is articulated beautifully in an article by Perri Klass in the Health Section of yesterday's New York Times. Respect is not just an issue for men -- the oft acknowledged perpetrators of violence -- but also for women. Respect is not just meant to be towards the elderly, it is to be targeted toward peers and parents.

Learning how to genuinely respect others is a lesson that can be applied in so many spheres of life, from riding the bus to marriage. Is respect a rare commodity these days? How far have we strayed from the "Yes, Sir" and "Yes, Mam" days -- and what does it take to instill those values in our children? How do we progress toward a more empowering understanding of both men and women -- so as to not always paint men as the aggressors and women as victims?

What you can do:

Read the NYTimes article. Talk to a young person about respect. Practice respect towards those around you -- whether in your home or on your way home.

Is "Three Glasses of Milk a Day" Too Much?

Is your physician (or your spouse) pushing you to have three servings of dairy a day? Is that wisdom (based primarily on nutrition guidelines in the US stating that we need upwards of 1000 mg of calcium daily), though well-intentioned, misguided?

A recent lecture Dr. Walter Willett of the Harvard School of Public Health addressed this debate head-on. He cited much scientific evidence (some strong and some weak) and concluded that 3 servings of dairy, particularly milk does not only not seem to benefit adults, but may actually be harmful in excess. Similarly, while milk likely leads to bone growth it does not prevent against fractures the way that it once was anticipated to.

The take-away message: consume dairy in moderation (1.5 servings a day is fine) and make sure I am getting enough Vitamin D in my diet and through outdoor activity.

For more information see my post at Society and Health.

Outrage Over Afghan Law

A law pending in Afghanistan appears to limit women's rights by actually legalizing marital rape and leaving the house without a male's permission was illegal. The wording is what struck me most, that it is the right of the man to have sex with his wife every fourth night (shown on CNN tonight). The idea of sexual and reproductive rights is one that warrants strong consideration. For example, the 1995 Beijing Conference (cited here) produced a Platform for Action stating

[t]the human rights of women include their right to have control over and decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination, and violence.

International human rights language makes clear that a woman has the right to decide when and how to use her body, not a man and not a relative. Furthermore,  it acknowledges "shared responsibility for sexual behaviors and its consequences." 

The Afghan law makes explicit that the desire of a husband to have sex trumps the rights of a wife to not want to have sex, this has enormous implications for legitimizing trauma and sexual violence (yes -- rape does happen within marriage -- no always means no), as well as has long term implications for family planning.

This case illustrates the enormous variability in conceptualization of sexual and reproductive rights and decision-making in different contexts. An essay on intimate partner violence (IPV) from the Peaceful Families Project highlights that in Muslim culture 'marital rape' is considered a contradiction in terms.  And while this Afghan law aims to politically legitimize the practice, it is important to note that many women and girls experience sexual violence and will continue to regardless of this legislation. It will take a social movement to eliminate these horrid practices. Much like the women's movement in the US served to overturn laws in US states that  exempted spousal rape as a crime until the 1970s.

More must be done to empower girls and to oppose those who impose barriers. Obama and other international actors have spoken out against this legislation that comes with the signature of our Afghan ally (he signed it at the end of last month). The result of this international pressure is yet to be decided.

A Question of Sustainable Screening

This month my first first-author publication was published in the Journal of Women's Health! I am extremely excited as it was the product of a two-year effort and became a really insightful article with the help of some really intelligent colleagues and collaborators. While I want to share with you highlights from the article, I'd also like to share some reflections on what I learned through the process.

The article examined what factors predict mammography re-screening (in the past 2 years) among Latinas living in California. This paper began as a study of all Latinas, but by the final iteration it focused on Latinas had at least one mammogram. Here are some of the major findings and considerations:

• Multiple factors influence mammography screening; those screened were older (60+ years), more educated, had health insurance, and reported having a 'usual source of care'.
• The most common reasons for not having a recent mammogram were cost, inconvenience, and lack of knowledge.
• Latinas who interviewed in Spanish were more likely to have been recently screened than those who interviewed in English (suggesting language might not be such a barrier to preventive health care use once access is attained).
• Increasing access to mammography screenings (both by reducing the cost and increasing the convenience) will likely improve re-screening among Latinas.

This was an incredible learning experience; one that I am so thankful to have had prior to graduate school and dissertation defenses. Nonetheless, there are a few key 'lessons learned' that I'd like to share. I hope these will serve as a reminder for myself and provide some comfort to others who will likely endure the same challenges and frustrations.

1. Listen. Embrace opportunities to invite in others to be a part of the publication process. I was so grateful to connect with collaborators at the CA Department of Public Health who were running mammography screening programs. It gave us a lot more confidence in our understanding of the problem and the interpretation of our data. 
2. Persist. Publishing this article was  a roller coaster ride. At first you think that your idea is the greatest one yet. Then, either through reviewers' comments or constructive criticism, you begin to doubt. It takes courage to work through the tough issues that need to be dealt with to improve the paper.
3. Revise! As focused as I thought the paper was when we began, there was way too much in there for a 2500 word article. Revisions focused the paper and resulted from thoughtful critique from reviewers and coauthors.
4. Relax. Once you submit that article there is no point in checking the website every day to see if the status of the article has changed (I never did that...). Enjoy the waiting because once you get the manuscript back your next few weeks are shot.

I am looking forward to working on some more publications, but I'm excited to have this blog so I can discuss public health issues that interest me any time. 

If you could publish in any area -- magazine, newspaper, journal -- what would you write about?

Fast Food and Obesity: A Causal Relation??

The New York Times reported on a recent Working Paper that examined changes in obesity among high-school students and excessive weight gain during pregnancy before and after a fast-food outlet opened in several cities across the United States. What did they find? Check out my blog post at Society and Health. 

Sister Site Launched!

I am excited to announce the launch of Society and Health (S&H) a blog that specifically investigates the social determinants of health. Several Harvard students (about 10 of us) will be contributing regularly to the blog. While we are all interested in "social factors" and how policies and programs can be better designed to account for them, we also have very different interests and perspectives on public health. I hope you check out the site and look at it often!

My posts at Society and Health will be linked from Veritas Health. I think this is a great opportunity to expand readership and try to get a better handle on how we can best disseminate new and interesting public health information.