Ahead of Martin Luther King Day, Remembering That Health Is Impossible Without Justice | Fortune

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Last month, President Trump signed into law the First Step Act, bipartisan legislation aimed at reforming the criminal justice system. Among other reforms, the Act increases the number of “good time” credits inmates can earn and apply towards a reduced sentence, modifies the “three strikes” rule so people with three or more convictions are automatically given 25 years in prison instead of life, and makes it easier for judges to opt out of delivering mandatory minimum sentences.

While the reach of these reforms is relatively modest, affecting only federal prison inmates—nearly 180,000 of the total incarcerated population of about2.2 million—the Act is nevertheless a step in the right direction. It points towards a justice system that is more what it was always supposed to be: just. It also points towards better health. Mass incarceration is a significant public health challenge in the US.

Read the full piece at Fortune.

The Public's Health: Treating Laura | Public Health Post

Laura is a 42-year-old woman who comes to see her primary physician. She is about 40 pounds overweight and has progressively worsening and painful osteoarthritis in her left knee. She has asthma, which keeps her out of work at least one day a month.
 
This is not an unusual presentation to any primary physician’s office. Her physician will look after Laura, prescribing inhaled steroids for her asthma, recommending weight loss through better diet and exercise, and prescribing anti-inflammatories for her painful arthritis until she gets to a point where she needs more or different medications, and later a knee replacement.  
 
And there is nothing wrong with treating Laura in this way: it is in fact good care by a responsible clinician. But why is Laura, at 42, overweight, and why has she long had asthma attacks?

Public Health Means Mental Health | Dean's Note

The World Health Organization defineshealth as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Over the years, public health has made great strides towards improving the health of populations, yet many key health achievements—from vaccination, to better sanitary conditions, to improved traffic safety—have been in the area of physical health alone. Too often, mental health, and the prevention of mental illness, has been an underappreciated public health challenge. At SPH, we have worked to correct this, by doing our part to elevate mental health to the same level of attention as physical health. We are, for example, one of the few schools of public health to offer a certificate in mental health and substance use. Mental health is truly a “first principle” of public health. Simply put, we must apply to the conditions that shape mental health the same population health approach we currently apply to the drivers of physical health. We cannot be healthy if we do not address these conditions, and the stigma that can prevent an honest discussion about mental illness.

University leaders must engage with public debate | Times Higher Education

When Dwight Eisenhower began his tenure as president of Columbia University in 1948, he was immediately thrust into a controversy. The university had appointed renowned scholar Manfred Kridl as an endowed chair for the study of Polish language and literature. The position was funded by the Polish government, but the Polish-American Congress claimed that it was part of a Russian “academic infiltration” campaign and demanded that the funding be rejected.

Eisenhower was new to academia, but did not shy away from the public debate. He stood squarely in defence of academic freedom, saying at his inauguration that “there will be no administrative suppression or distortion of any subject that merits a place in this university’s curriculum. The facts of communism, for example, shall be taught here…no intellectual iron curtain shall screen students from disturbing facts.”

The Burden of Substance Misuse | Dean's Note

Last November, the National Center for Health Statistics reported that, between 2016 and 2017, US life expectancy fell from 78.7 to 78.6 years, marking the third consecutive year the US has seen a life expectancy decrease. A core driver of this decline is the ongoing challenge of drug overdose in this country. There were 70,237 drug overdose deaths in the US in 2018 alone, 47,600 of which were linked to opioid misuse. The high number of overdose deaths, and the even higher number of people who struggle with substance use disorders, stands in contrast to how we tend to think about this problem. Too often, we regard people with substance use disorders as somehow separate from us, existing on the fringes of society. Yet the numbers show this is not the case. People who struggle with substance misuse are our neighbors, friends, and family. For this reason, when we marginalize this population, we are often cutting ourselves off from those closest to us. Before the holiday intercession, we introduced the first two parts of a “trilogy” on populations whose health challenges are often overlooked due to stigma or socioeconomic marginalization. Today, we will conclude this series with a look at a core driver of such marginalization—the public health challenge of substance misuse.

Nearly 5 percent of total years of life lost globally are attributable to alcohol and illicit drug use. It is estimated that there are 185 million people globally who use illicit drugs, and opioid dependence is the principal contributor to the burden of illicit drug dependence worldwide. The National Comorbidity Survey Replication estimates that about 4 percent of adults in the US have experienced a substance use disorder in the past year, or 1 in 25 adults. This is likely a substantial underestimate given the known high prevalence of substance misuse among homeless individuals and other groups who are missed in national surveys. Substance use disorders are associated with substantial morbidity and mortality, loss of economic productivity, unemployment, and intimate partner violence, and go hand in hand with psychiatric disorders and other comorbidities, including weight gain and obesity.

Substance use disorders are only the “tip of the iceberg” in terms of population health consequences of substance misuse. For example, binge drinking is a very common problem in the US that can lead to liver disease, injury, neurological damage, sexually transmitted diseases, and unintended pregnancy. Binge drinking is especially common in particular populations, for example among military personnel, where it has been associated with psychiatric comorbidity and risky behavior. Several of our faculty members have made substantial contributions to the field of substance misuse, and I will not here attempt a comprehensive list for fear of missing important work. In particular, the work of Professor Richard Saitz has long noted the importance of thinking about unhealthy alcohol use as a frequently overlooked contributor to population morbidity.

Turning our attention to drug-related incidents, principally deaths that have informed much of the recent concern with opioids in the state and nationwide, colleagues and I reviewed the available literature on unintentional drug overdose globally. The review concluded unequivocally that globally overdose is on the rise, particularly in rural areas and especially from prescription opioids. From 1999 to 2008, hospitalization rates for overdoses in the US increased by 55 percent, costing about $737 million in 2008, a figure that is undoubtedly dwarfed today. The figure below summarizes data that has long made clear the dramatic burden of mortality linked to substance misuse, showing that drug-related deaths have exceeded motor vehicle deaths in this country for nearly a decade.

Figure 1.   Motor vehicle accident deaths have declined while drug overdose deaths have increased in the past thirty years. M Warner, LH Chen, DM Makuc, RN Anderson, AM Miniño. Drug poisoning deaths in the United States, 1980–2008. NCHS Data Brief. 2011;81(22):1–8. http://www.cdc.gov/nchs/data/databriefs/db81.htm

Figure 1.
Motor vehicle accident deaths have declined while drug overdose deaths have increased in the past thirty years. M Warner, LH Chen, DM Makuc, RN Anderson, AM Miniño. Drug poisoning deaths in the United States, 1980–2008. NCHS Data Brief. 2011;81(22):1–8. http://www.cdc.gov/nchs/data/databriefs/db81.htm

As the availability of prescription opioids has increased across the US, illicit drug use has gone down in many areas. However, one unexpected consequence of this shift is that many individuals who would not be likely to use heroin otherwise are introduced to opioids through prescription opioids, and then later turn to heroin as their tolerance for the substance increases or they no longer have access to the medication. One result of this shift is that heroin use is actually starting to increase again, especially among affluent people living in the suburbs, a very different group from those generalized as having heroin use disorders in decades past.

Importantly, stricter policing practices, not atypically linked to the rise in drug-related overdoses, can themselves contribute to increasing drug-related deaths, principally as people with substance use disorders move underground and witnesses to overdoses are reluctant to call for help. Perhaps optimistically, the growing burden of drug-related overdose has made it abundantly clear that drug-related overdose is not simply a law enforcement or public safety issue, but a public health issue. One major aspect of public health relevance is that overdose is usually preventable, and individuals rarely overdose alone, providing a unique opportunity to avoid death, particularly for those witnessing an overdose. Provision of the opioid antagonist naloxone, a practice that is being implemented in many areas, is one example of a way to potentially stop the harm of an overdose before it leads to death. Hearteningly, some innovative efforts across the US, including several here in Massachusetts, are taking the initiative to move beyond thinking of substance use as a legal issue to thinking of it as a public health issue.

study published in the Proceedings of the National Academy of Sciences brought home the consequences of drug use by simply and effectively showing that if the death rate among those aged 45 to 54 had continued to decline the way it had between 1979 and 1998, we would have avoided half a million deaths between 1999 and 2013, comparable to the number of lives lost to AIDS in the US; I referred to this paper in a prior Dean’s Note.

It is important to note that mortality is far from the only consequence of drug use. Other associated outcomes include hospitalization cost and lost work productivity. Additionally, consequences of nonfatal overdose among victims include cardiac and muscular problems, cognitive impairment, renal failure, and other injuries. Moreover, following the lifecourse paradigm, effects of substance use can spill over from generation to generation; maternal smoking during pregnancy is associated with low birth weight, among other effects in offspring, and using alcohol and other substances during pregnancy is associated with a myriad of outcomes, including pre-term birth, placental abruption, neonatal withdrawal, and cognitive deficits.

The growing focus on non-medical opioid overdose state-wide and nationwide is welcome, but this approach deals only with a small part of a much larger problem with the use of substances worldwide. The burden of substance use is very much a chronic challenge to population health that has long been underappreciated and on the fringes of mainstream public health. Unfortunately, this marginalization is accompanied by substantial shortage in opportunities for treatment for those with substance dependence, attendant unmet need, and an even deeper paucity of engagement around prevention of substance use and misuse. The recent attention to the issue is an important, if small, turn in the right direction.

I hope everyone has a terrific week. Until next week.

Warm regards,

Sandro

Resolutions for a Healthier World | Dean's Note

We have reached the end of another year. It is a time for taking stock, for looking back on the world in 2018 and our school’s place in it. At the school, we have had a full year indeed, giving us much on which to reflect. From our community events, to our activism on issues like gun violence and transgender rights, to our scholarship on everything from e-cigarettes to maternal mortality, we have been deeply engaged in the mission of promoting health. At the heart of this mission is our core purpose, “Think. Teach. Do. For the health of all.” We aspire to generate cutting-edge scholarship, to innovate in education, and to engage with social movements and the broader health conversation. We see this as core to achieving our goal of a healthier world. As we look to continue this mission in 2019, I would like to suggest three resolutions—each reflecting a pillar of “Think. Teach. Do.”—to help us promote health in the coming year.

These Holidays, A Reminder That the Health of the Many Depends on the Health of the Few | Fortune

Tiny Tim is not the main character of A Christmas Carol. That would be Ebenezer Scrooge, the old miser who, through the intercession of three spirits, changes, by the end of Charles Dickens’ classic tale, into a good man. It is hard to read A Christmas Carol, however, or watch one of its many film adaptations, and not feel Tiny Tim is somehow its heart. Born sickly, into a family without the means to properly care for him, he seems fated for an early death, until Scrooge’s reformation, when the old man decides to help the boy, becoming a “second father” to him, and providing the financial support that ensures Tiny Tim will live.

Dickens announces this uplifting development in the story’s closing lines; it is the tale’s emotional payoff, the final indicator that the battle for Scrooge’s soul has been won by his better angels, that the bitter man he once was is no more. By caring for Tiny Tim, Scrooge at last comes into his own as a fully human being.

Making Aging Healthier | Thrive Global

When Jeanne Calment was 90 years old she sold her apartment to a lawyer named Andre-Francois Raffray on a contingency contract. The deal was that he would pay her 2,500 francs a month (about $400) until her death, whereupon the apartment would become his. This would have been a nice arrangement for Raffray, were it not for the fact that Calment lived for another 32 years, to the age of 122—the longest human life on record.