Health care in the United States is long overdue for an upheaval. The mismatch between costs, by far the highest in the world, and health outcomes, among the worst in the high‐income world, has long been glaring. Perhaps the good news is that the time for such an upheaval has come. At least 4 forces have been gathering steam, each promising to change the nature of health care and, in so doing, influence population health.
How Art Reflects the Conditions That Create Health | Dean's Note
Population health is shaped by a range of economic, cultural, and environmental factors. Economic trends, political policies, climate change, the rise of social movements all have a hand in creating or undermining health. These conditions, of course, contribute to much more than health. They shape all aspects of the world we live in. They also inspire art as a representation of our world, holding a “mirror up to nature” that allows us to better understand the forces that shape the human story. A note, then, on the intersection of art and population health, and how a deeper understanding of art can make us better students of the conditions that influence the health of populations.
It was with this in mind that we last weekend hosted, in partnership with the Boston University Center for the Humanities, a symposium, “Humanities Approaches to the Opioid Crisis.” The event brought together scholars, artists, and health professionals to explore how art can open a window into the conditions that created this epidemic. As the opioid crisis has worsened, is has become clear that this problem is too big to approach from a single perspective. We must widen our gaze, and see the crisis through the lens of many disciplines, including art, if we are to stop it. We should take a similarly broad view of other health challenges, using the insights of art to help us deepen our empathy, expand our imaginations, and find solutions we might have otherwise overlooked.
The Public's Health: Spending Too Much On the Wrong Things | Public Health Post
Americans spend half as many days in hospital as do persons living in other high-income countries. We take fewer pills per person. We log fewer office visits and have fewer doctors per capita. Yet we spend 2-3 times as much as other countries on health care and have poorer health outcomes. In 2017, we spent $3.5 trillion. Why? Because we overpay.
How the Humanities Can Help the Opioid Crisis | Thrive Global
The opioid epidemic is the public health crisis of our time: with 64,000 annual deaths, it has surpassed the peak losses of all other epidemics, including HIV/AIDS. The financial toll is staggering: over $500 billion annually. Myriad solutions have been proposed, some implemented. And yet, the overall national response remains tepid.
We believe that a major reason for this is the prevailing tendency to see the opioid epidemic as a problem of the other. Elevating the human dimension of the crisis, and recognizing that this is not about them, but about us can go a long way towards redressing our predicament. Fortunately, a vast literature exists to aid our efforts because some of the most eloquent literary minds have written about addiction to opioids.
Brett Kavanaugh, Privilege, and Our Health | Fortune
In his book, A Theory of Justice, the political philosopher John Rawls proposed an idea for creating a better society. He imagined a new social contract, one designed from behind a “veil of ignorance,” where the designers are kept unaware of the position they will occupy in the society they are to build. This allows them to approach their task free from the biases of personal self-interest. They do not know if, in this new society, they will be born gay or straight, white or a person of color, privileged or lacking money and social clout. This way, they will have an incentive to build a world where all can thrive.
Unfortunately, we have fallen far short of Rawls’ vision, and our health has suffered for it. Far from being designed from behind a veil of ignorance, our society is one where entrenched, unearned privilege gives advantages to the few, at the expense of the many. In the US, the richest one percent of Americans now live between 10 and 15 years longer than those at the bottom of the economic ladder. Americans whose skin is not white or who are LGBT are likelier to face bigotry, exclusion, and poor health than those who do not share these characteristics. And, as the #MeToo movement has shown, our society has failed to prevent endemic sexual harassment and abuse.
The Public's Health: Good App Hunting | Public Health Post
Public health and medicine are in a moment of digital euphoria. We have convinced ourselves that mhealth (mobile phone) technologies will improve the health of millions. After all, there are 6 billion smartphones out there and more than 300,000 stand-alone health apps on the market ready to be uploaded. Suddenly, the promises of behavior change to improve the care of highly prevalent conditions (obesity, diabetes, anxiety, insomnia) are scalable. But as behavioral health facilitators, will phone apps work and how will we know if they do?
More research on ‘dying healthy’ will also help us live healthier | STAT
Helping people live longer has been a central goal of medicine for decades. The quest to extend life raises an interesting question: Should we keep investing in research aimed at adding even more years to the already impressive gains in the average life expectancy that occurred during the 20th century?
Changing the Structures That Enable Sexual Harassment and Assault: A Public Health Imperative » SPH | Boston University
It has been nearly one year since The New Yorker and The New York Timespublished their investigations into Harvey Weinstein. In that time, stories of sexual harassment and violence have emerged from seemingly every corner of our society. We have seen high-profile allegations against prominent figures in politics, entertainment, and journalism, among other fields—and, just this week, a reckoning, when Bill Cosby was sentenced to 3 to 10 years in prison for sexual assault. These have done much to catalyze our present overdue reckoning with endemic sexual abuse in our society. Yet, as Thursday’s Senate Judiciary Committee hearing demonstrated, we are far from a national consensus regarding the voracity and import of these claims.
Moreover, as the many personal stories of abuse have shown—often shared using the viral #MeToo hashtag—the vast majority of sexual harassment does not make headlines. A chart from the Center for American Progress shows how common sexual harassment is in almost every industry (Figure 1). I note that even these figures almost certainly under-record the prevalence of sexual harassment in the US population, and do not include particularly high-risk populations like sex workers.
Figure 1. Total sexual harassment charges filed, by industry, fiscal years 2005 through 2015
Frye J. Not Just the Rich and Famous. Center for American Progress Web site. https://www.americanprogress.org/issues/women/news/2017/11/20/443139/not-just-rich-famous/Published November 20, 2017. Accessed November 21, 2017.
That systemic sexual abuse is now being more fully addressed suggests we may have finally begun to reckon with the gender inequities and entrenched power imbalances that allow such harm to flourish. The existence of these conditions shows that this crisis is not just a matter of powerful people using their position to hurt others, but a failure of society to stand up for the values of justice and inclusion that should be a bulwark against exploitation of any kind. It also opens the door to how public health can help mitigate the problem of sexual harassment and violence, by working to build a society where this is no longer acceptable.
This epidemic has long been a cruel fact of life for the 321,500 Americans over the age of 12 who are sexually assaulted or raped each year; the very ubiquity of sexual violence places it at the heart of public health. One in five women, and one in 71 men, will experience rape at some point in their lives, yet 63 percent of sexual assaults are not reported to the police. A small silver lining appears to be that sexual assault and violence seem to be decreasing in the US. According to the Rape, Abuse & Incest National Network (RAINN), the rate of sexual assault and rape has fallen by 63 percent since 1993. Additionally, harassment in the workplace appears to be decreasing, with the best data on this (General Social Survey data) showing a decrease from 6.1 percent in 2002 to 3.6 percent in 2014. As with other challenges to population health, sexual violence affects some populations more than others, with marginalized groups suffering most. Women, especially women of color, experience disproportionately high rates of sexual violence—90 percent of adult rape victims and 82 percent of juvenile rape victims are female. Rates of sexual violence are comparable or higher among LGBT populations compared to heterosexual populations. Transgender populations are at a particularly high risk of experiencing sexual assault—for example, 12 percent of students expressing a transgender or gender non-conforming identity in grades K-12 reported experiencing sexual violence. Although it is difficult to compare populations due to underlying demographic differences, age-adjusted estimates suggest that sexual assault of people with disabilities is about twice as high as for those without disabilities.
In addition to the trauma associated with harassment and abuse itself, there is abundant evidence that sexual harassment and violence is associated with subsequent poor health. A recent study found workplace sexual harassment exposure is linked with a higher level of depressive symptoms. Other studies have reported similar findings, including an analysisthat linked harassment to feelings of anger, self-blame, and self-doubt. The effects of sexual violence include self-harm, substance abuse, depression, post-traumatic stress disorder (PTSD), sleep disorders, and suicide attempts. In the US army, women with administratively recorded sexual assault victimization had higher odds of later mental health treatment, attempting suicide, demotion, or attrition. Early lifecourse sexual assault has been linked with an elevated risk of HIV infection and teenage pregnancy. As I have reflected in previous notes, exposure to traumatic experiences affects health across the lifecourse.
The goals of public health are inseparable from the goals of social justice—to create a world where the conditions around us allow everyone to thrive, where there is equity between groups, where inclusion creates the networks and bonds that nurture well-being. A society characterized by systemic sexual harassment and violence is one where these goals have not been reached. Addressing this problem means addressing the core concerns of public health—the improvement of conditions in which people live and work, and the closing of health gaps—to create a culture that no longer accepts sexual violence and the broader injustices that enable it. It means reckoning with perpetrators and identifying humane and evidence-informed ways to ensure that they do no further harm, and creating a world where collective action ensures that sexual violence is unacceptable, protecting all. The military provides an example, in microcosm, of how improving community conditions can mitigate the likelihood of sexual harassment and assault. In a recent study, our team foundunit support—including factors such as comaraderie and acceptance of women as part of the team—was linked with lower risk of sexual misconduct. This suggests the key role of equity, respect, and inclusion in mitigating assault and harassment.
How can we help foster these conditions? First, we can continue working towards a community that prizes fairness, equity, and, above all, social justice, where all are treated with dignity and respect. To do this, SPH, and the broader BU community, remain committed to providing resources for students, faculty, and staff to report any harassment or assault they may have experienced. As outlined in a recent message from Provost Jean Morrison, BU’s Sexual Misconduct/Title IX Policy and Student Sexual Misconduct Procedures will remain the same, despite the issuing of new guidance from the US Department of Education. The Sexual Assault Response & Prevention Center (SARP) is also on hand to provide confidential support and promote prevention through educational programs. The Office of the Ombuds is an additional safe space where members of the BU community can discuss concerns about sexual misconduct in a confidential setting. Finally, Boston University is implementing mandatory, University-wide sexual misconduct training for all students, faculty, and staff. Last week, the Provost sent an email to the BU community outlining this training; details can also be found on the University’s website. This training is an important opportunity for us to become ever-better at ensuring our community remains a safe, respectful space for all.
Second, we can lend our voice to the ongoing discussion around the issue of harassment and sexual violence. Public health is inextricably linked to the broader conversation—it is this conversation that shifts attitudes towards making the acceptable unacceptable, in order to improve the social, economic, and environmental conditions that shape health. This fits with our role as an academic community—to contribute to the ongoing discussion about health, and, through this engagement, to nudge public opinion in a healthier direction. This is, in part, what I am trying to do with this note, and what we can all do in our respective spheres. Systemic inequities, and the poor health they create, thrive on society’s lack of engagement with core challenges. It is only by having honest, sometimes difficult conversations that we can lay the groundwork for a healthier world.
Finally, in an effort to facilitate such conversations, we will be hosting a discussion about the Kavanaugh Supreme Court nomination hearings and sexual violence on Tuesday, October 2, from 2:30 to 5 p.m. in Hiebert Lounge. This event provides an opportunity for members of our community to be together and discuss the topics emerging around the Kavanaugh Supreme Court nomination hearings—specifically, the topics of sexual violence, support for survivors, and adolescent perpetration of sexual violence. The event will be informal, and any thoughts, questions, and perspectives are welcome. All students, staff, and faculty are invited. Professor Emily Rothman and SPH alumna and instructor Nicole Daley will help begin the conversation. We will be joined in the conversation by Provost Jean Morrison, Dr Lisa Fortuna, and Professor Megan Bair-Merritt.
If there is anything positive to take from the disturbing news emerging from recent events, it is that we may use this as a time to engage in thoughtful conversation, and to redouble our efforts to create the conditions that improve the health of all.
Until next week.
Warm Regards,
Sandro
Acknowledgement: I am grateful to Professor Emily Rothman, University Ombuds Francine Montemurro, Meaghan Agnew, Kara Peterson, Catherine Ettman, and Eric DelGizzo for their contributions to this Dean’s Note.