The Social Medicine Portal

2009 Spirit of 1848 sessions at APHA

Both for those readers who will be attending next week’s APHA (American Public Health Association) Convention and particularly for those who will not be there, we wanted to share this year’s Spirit of 1848 sessions.

Berlin Revolution, March 1848

The Spirit of 1848 is happy to share our final program for the 137th annual meeting of the American Public Health Association, with the theme of “Water and Public Health” (November 7-11, 2009; Philadelphia, PA). SESSIONS

All Spirit of 1848 sessions will be held in the Philadelphia Convention Center (hereafter referred to as “PCC”).

Monday, November 9, 2009
10:30 am to 12 noon:
The Social History and Politics of Water and Public Health (Session 3162.0, PCC 113A)

10:30 am
INTRODUCTION: Social history and the politics of water and public health.
Anne-Emanuelle Birn, MA, ScD

The introduction will lay out key factors in critically examining the social history and politics of water and public health, especially in relation to water access and sanitation. Examples of the politics of past political and social struggles for the right to water and sanitation in Europe and throughout the Americas will be used to set the context for the papers presented in the session.

10:35 am
Unclogging obstacles to water and sanitation coverage: the promise and perils of comparing Philadelphia’s history with the crisis in the developing world.
Niva Kramek, MES and Katryn Bowe, BA

Less than one hundred years ago, annual typhoid outbreaks in Philadelphia killed more than 400 people each summer for 30 years. Contaminated drinking water and the lack of a system for removing human and animal waste plagued the city, presenting many of the same public health challenges facing developing cities today. Using Philadelphia’s water history as a case study in conjunction with current practices in several developing locations, this paper will address essential issues confronting clean water and adequate sanitation: political disregard for water issues until moments of crisis; complex trans-boundary cooperation requiring a watershed perspective; the inability of epidemics alone to prompt action; persistent difficulties in financing these systems; and deep-rooted taboos surrounding human waste that discourage changing norms. Efforts to provide clean drinking water and wastewater treatment that is environmentally and economically sustainable benefit from understanding how contemporary challenges were addressed in the past. As the first city in the world to provide free drinking water and as an innovator in centralized water delivery methods, Philadelphia’s history provides inspiration. However, though understanding history can prevent repeating past mistakes, directly copying what once worked misses opportunities for more equitable, efficient, and sustainable development driven by the unique character of many areas, and of economic, technological, and social advances. Philadelphia’s mistakes demonstrate what to avoid, and it has much to learn from innovations in today’s developing areas, at a time when waste must be used as a resource and small scale technology and financing have become important tools.

10:55 am
Building inequality: sewers, civic ideals, and public health in Los Angeles, 1873-1891
David Torres-Rouff, PhD

Infrastructural development is a critical historical process within which to explore the relationship between water, human rights and public health. Throughout the nineteenth century, civic leaders in U.S. cities built sewer systems to enhance the purity of municipal waters and improve public health. Los Angeles’ city council began building sewers in 1873, converting miles of open water canals, or zanjas, into underground sewers over the next twenty years. While not an unusual aspect of urban development, sewer building in Los Angeles commenced following the resolution of an acrimonious, fifteen-year long battle between Mexican Californians, who advocated common ownership and equitable, cost-free distribution of the city waters, and Anglo Americans who preferred private ownership, fees for service, and the separation of waste, agricultural, and potable waters into separate pipes to improve the “purity” of the water supply. Following a decisive political victory in 1872, Anglos built a sewer system that fundamentally altered people’s relationship to water, converting it from a communal resource into a commodity. However, city leaders failed to build sewers where Mexican and Chinese Angelenos lived. In addition to exposing these neighborhoods to greater health risks, unequal sewerage created experiential asymmetries between Mexican/Chinese and Anglo American districts, provoking condemnations of Chinese and Mexican residents as dirty and diseased. Over time, these stereotypes have worked in lock step with the spatial and institutional barriers resulting from infrastructural inequality to limit marginalized populations’ claims to human rights in Los Angeles.

11:15 am
Critical reflections: on history, culture, and struggles over access to water and sanitation.
David S. Barnes, PhD (discussant)

As discussant, I will reflect critically on the presentations included in this session, emphasizing the practical value of historical perspective and attention to cultural factors in contemporary struggles over access to water and sanitation.

11:30 am
Question & answer period

Monday, November 9
2:30 pm to 4:00 pm:
Macroeconomics, Political Systems, and Population Health and Health Inequities (Session 3361.0, PCC 108B)

2:30 pm
Introduction to Politics of Public Health data session
Catherine Cubbin, PhD

2:35 pm
Health inequities in global context: evidence from the World Values Survey.
Jason Beckfield, PhD and Sigrun Olafsdottir, PhD

The existence of social inequalities in health outcomes is well established in social science research from multiple disciplines. One strand of research focuses on inequalities in health within a single country. A separate and newer strand of research focuses on the relationship between aggregate inequality and population health across countries. Despite the theorization of (presumably variable) social and political conditions as determinants of population health and health inequities, the cross-national literature has focused on population health as the central outcome. Controversies currently surround macro-structural determinants of overall population health such as income inequality, the welfare state, and economic development. We argue that these debates would be advanced by conceptualizing inequalities in health as cross-national variables that are sensitive to social conditions. Using data from the third wave of the World Values Survey, we examine cross-national variation in inequalities in health. The results reveal dramatic variation in variations in health according to income and education. We find that this variation in the socioeconomic gradient can be partially accounted for by cross-national differences in economic development, population health, and, especially, income inequality. We conclude by discussing the implications of this research.

2:55 pm
Income support and women’s health reform in developing countries: the impact of microfinance.
Deborah Viola, PhD

Health systems and pathways to better health are shaped by the economic environment and the social structures and political forces that govern each country. The objective of this study is to highlight the link between globalization and women’s health reform by specifically considering the World Trade Organization Agreement on Agriculture (AoA), the microfinance response, and their health impact on women in developing countries. Low socioeconomic status has been linked to a great burden of disease and death in developing countries. Studies have illustrated the impact of the AoA on decreased earnings and employment, poverty, and reduced access to education and health care services. These burdens further exacerbate existing gender inequalities within developing countries, since agriculture practiced by the poor is often considered “women’s work.” Several studies have explored the role of microfinance in rejuvenating urban agriculture and putting poor women “back to work.” However, researchers have rarely tested whether social programs designed to alleviate poverty or otherwise improve economic well-being for large segments of the population are linked with health improvements. Further, researchers have questioned the merits of existing quantitative analyses in capturing the impact of economic and development policies on women’s health status in developing countries. We present preliminary qualitative case studies of women and the use of microfinance to suggest that such a relationship does exist and demonstrate the need for more empirical, multidisciplinary work to be done in this area if we are to truly impact women’s global health.

3:15 pm
Public health implications of economic recession.
Jessica M. Robbins, PhD

Based on literature review and local health informants, we attempted to assess foreseeable public health effects of economic recession, with a specific interest in effects that could be addressed by local public health action. Poverty, unemployment, and financial strain are incontrovertibly associated with increased mortality and poorer health in all populations, but whether and how these effects change during recessions is unclear. Overall effects of recession on mortality are disputed, but considerable evidence suggests that at national levels cardiovascular and total mortality usually decline during recessions, while suicide may increase. Birth rates may decline, but no studies on specifically urban populations confirm this. Mental health symptoms appear to increase during recessions for the employed as well as those losing work. Increases in distress and morbidity may disproportionately affect women. Pessimism and uncertainty about the future are strongly associated with ill health. Effects on smoking and alcohol use are complex, as population-wide both usually decline during recessions, although the unemployed may be least likely to quit smoking. Negative health impacts of unemployment may be most severe at the time when job loss occurs. Early accounts suggest that, in Philadelphia, individuals are postponing or forgoing needed hospital-based medical care. More patients are using public health clinics, and more of them are uninsured. Evidence on the effects of recession for specific population groups, including vulnerable populations and different age groups, is largely unavailable. Policy implications and areas in which local public health efforts might be effective will be discussed.

3:35 pm
Nancy Krieger, PhD (discussant)

As discussant, I will reflect critically on the presentations included in this session, as framed by a discussion of the importance of analyzing political systems and priorities is essential for understanding and improving population health and rectifying health inequities.

3:45 pm
Question & answer period

Monday, November 9, 4:30 pm to 6:00 pm:
Indigenous Methodologies in Public Health Research: An Issue of Social Justice & Good Science (Session 3438.0, PCC Auditorium)

4:30
Introduction: Indigenous Methodologies in Public Health Research: An Issue of Social Justice & Good Science
Nancy Krieger PhD

In this introduction, as Chair of the Spirit of 1848 Caucus, I will briefly describe the origins, objectives, and format of our session, whose content was jointly organized by Vanessa Watts and Suzanne Christopher. This session will focus on methods for advancing discussion and practice of the use of Indigenous methodologies in public health research. Many researchers involved in research with Indigenous peoples have raised questions regarding whose perspective is informing the research process and what it means for those involved. Indigenous methodology is an approach to culturally appropriate knowledge production and dissemination. The purpose of indigenous methodologies is to ensure that research is done in a respectful, ethical manner that is valuable and useful from the view of Indigenous people. In this session, we will explore these issues in relation to the three themes of the Spirit of 1848 caucus: (1) the social history of public health, (2) the politics of public health data, and (3) progressive pedagogy, and our overall focus on links between social justice and public health.

4:35
Legacy of conventional research with Indigenous communities and its relevance to current public health research.
Suzanne Christopher, PhD and Vanessa Watts, PhD

Recent theorists and commentators have pointed out the history of deleterious effects brought about by conducting research conventionally in Indigenous communities and with Indigenous individuals. We summarize this research and explore the relevance of this history to current public health research. Much of the previous conventional research is regarded as an expression of colonialism because it has exploited, marginalized, ignored contributions, pathologized and problematized communities and individuals. Using examples from the UN Principles and Guidelines for the Protection of Indigenous Heritage and UN Declaration on the Rights of Indigenous Peoples, we will discuss rights that Indigenous people have regarding indigenous methodologies and indigenous data. We examine underlying presuppositions and values that gave rise to this conventional research. We end by providing a definition of indigenous methodologies and indigenous knowledge that can be usefully set into dialogue with mainstream public health approaches.

4:50
The politics and purposes of Indigenous public health data.
Bonnie Duran, DrPH

This presentation will provide a brief genealogy of data collection and use (a) about “Indian Country”, and (b) from “Indian Country” and will (c) review current day Tribal recommendations and regulations regarding research approvals and data sharing. The presentation will also provide a brief introduction to the “International Indigenous Health Measurement Group” and other national and international efforts to expand the sources of data and improve the collection, analysis, interpretation and dissemination of information useful for improving the health of Indigenous populations.

5:05
Teaching Indigenous research methodologies.
Felicia S. Hodge, DrPH

Teaching Indigenous research in public health research is a valuable tool to advance the trajectory of health and wellness. Use of Western teaching methods is replaced with storytelling, grounded theory, and group process. Learning how to teach, how to listen, and when and where to place the perspectives of stakeholders addresses the barriers, strengths, and value of Indigenous research methodology.

5:20
Graduate researchers in Aboriginal health & Indigenous methodologies.
Katherine Minich, MHSc and Krista Maxwell, MA, PhD(C)

This paper will explore perspectives on self-location and identity, cross-cultural collaboration and Indigenous methodologies amongst Indigenous and newcomer graduate students doing research in Aboriginal health in Canada. The Institute of Aboriginal People’s Health, established in 2000 as one of the Canadian Institutes of Health Research, has made efforts to develop Aboriginal capacity in health research through its support for national Network Environments for Aboriginal Health Research (NEAHRs). At recent annual national gatherings of graduate students doing research in Aboriginal health through the NEAHRS, close to 50% of participants have self-identified as Aboriginal. Issues of partnerships with Aboriginal communities and ethics guidelines specific to Aboriginal health research have featured prominently in discussions at these gatherings. Less attention has been given to critical reflection on researcher identity, the relevance of Indigenous methodologies, and the complex and challenging power dynamics amongst researchers, and between researchers and Aboriginal communities. We will present on a participatory action-research project with graduate students which aims to stimulate individual and group reflection and discussion on these issues. This project is being jointly developed and executed by an Indigenous and a newcomer graduate researcher, and will be co-presented.

5:35
Native American pedagogy and health.
Brenda Seals, PhD, MPH (discussant)

Native Americans are challenging to reach with health education messages. Many elders and youth grow up with English as a second language. Few public health professionals understand either the diversity of the over 500 federally recognized tribes or the unique history and culture that are essential for effective messaging. Native Americans experience more poverty and substandard quality of life compared to other minority groups. Providing health care and outreach to Native Americans is also complicated by unique access to health care service issues and desires to blend traditional practices with Western Medicine. Despite these barriers, much can be done to improve messaging and education for Native Americans including: a) Building messages around family issues; b) Localizing messages focusing on community members’ experiences, art work and traditional stories; c) Providing story scenarios as the basis for health messaging; and d) Supporting community mobilization to help tribes and urban partners fully participate in and have ownership over health messaging.

5:45
Question & answer period

Tues, NOV 10, 8:30 am to 10:00 am:
Community perspectives on community-based progressive pedagogy (Session 4068.0, PCC 113A)

8:30 am
Introduction.
Suzanne Christopher, PhD and Lisa D. Moore, DrPH

8:35 am
“Will they really use our work?”: The importance of University/Community partnerships in creating relevant service learning assignments.
Jean M. Breny Bontempi and Chris Cole

Engaging public health students in learning the critical skills of conducting community-based participatory community assessments is made much more relevant when they are able to partner and collaborate with the community in a “real world” class exercise. This presentation will highlight an example of successful collaborative work with a community-based organization and a graduate community health education class to complete an agency-wide assessment for the agency’s strategic planning process. The project was designed and implemented entirely with equal partnership between course faculty and students and staff of AIDS Project New Haven (CT). Barriers to requiring service learning assignments, like this, from graduate students include their full-time work schedules, personal lives, and commuting distances resulting in a lack of time needed for students to work on-site at an agency. This experience showed that by taking on a participatory approach to conducting assessments and assigning students to working groups that met their own needs, the success of completing project was increased. The results for students, in working on a real project that will help an organization do its work better, was a motivating aspect of the process was the realization that their work would be used by the organization to improve services. By collaborating with community organizations, linking current public health issues at the local community level, and by researching organizations in the community, students realized that even the most diverse populations can be united by common goals. Making a “real difference” in the “real world” is at once inspiring and empowering.

9:00 am
Community based participatory research as a lens for reconceptualizing service learning: diverse urban students bridging campus and community.
Ester R. Shapiro, PhD, Michelle Rogers, BA, Asi Yahola Somburu, BA, Genita Johson, MD, MPH, Brian K. Gibbs, MPA, PhD, Naomi Bitow, MPH, Roland Smart, BA, and Felton Earls, MD

Service learning usually refers to residential college students assumed to be outsiders to the organizations they serve and focused on student learning and civic engagement rather than community benefit. Traditional service learning models exclude the majority of students enrolled in higher education, including ethnic minority and working-class students, who did not enroll in college full-time immediately after high-school, are commuter rather than residential students, work and care for families, and are already engaged in their communities. Community Based Participatory Research focused on health disparities offers a unique opportunity to inspire these students to undertake health professions and health research careers promoting health equity, through collaborative research addressing community problems in meaningful ways. CBPR research training supports diverse students, themselves carrying the consequences of health and educational disparities, in transforming academic and professional paths in ways that benefit their communities. While often regarded as deficits, first-hand experiences of health consequences of inequality, when combined with learning about the power of knowledge-based social action, inspire students to see participatory research as bridge and foundation for “making a living while making a difference”. This paper presents a collaboration between the University of Massachusetts at Boston, Harvard School of Public Health and Roxbury’s Cherishing Our Hearts and Soul Coalition in mentoring students who are members of communities affected by health disparities to gain research, community organizing, and policy/advocacy skills through CBPR. Presenters include faculty and community mentors and student researchers describing their experiences bridging professional development and community activism through participatory research.

9:25 am
Question & answer period

Tues, NOV 10, 12:30 pm to 1:30 pm:
Social Justice & Public Health: Student Posters (Session 4162.0, PCC Hall A/B)

This session highlights posters prepared by students of public health and health-related programs focused on intersections between social justice and public health from a historical, epidemiological, global, and/or methodological perspective.

Board #1: Evaluating the progress made towards Universal Health care for Philadelphians six years after a successful ballot referendum.
Jenny R. Pahys

Philadelphia is experiencing a health care crisis, specifically among poor and minority populations. After a successful grass-roots campaign, all wards in Philadelphia overwhelmingly approved a ballot referendum supporting universal health care for all Philadelphians in 2003. In response to this political mandate, the authorities instructed the Philadelphia Department of Public Health to act. The Department commissioned a report released in May 2005 titled Decent Health Care for All. Determining that an insurance strategy to provide health care for all Philadelphians was not feasible, this report called for the formation of an influential advisory board to best organize existing resources to efficiently deliver health services to underserved populations, produce strategies for better financing of care to vulnerable populations and to facilitate efforts to integrate ‘safety net’ programs for the uninsured. The mandate as such was thereby derailed.
This project assesses the progress made by the city towards acting on the primary suggestions outlined in Decent Health Care for All. This assessment discerns whether an effective advisory board and a health care agenda have been assembled and whether progress has been made towards the board’s primary objectives. Second, changes in health status of Philadelphians and available health care resources over the ensuing six year period are analyzed against the values underlying the original mandate. Finally, reflections on the progress to date are presented, including an analysis of the obstacles and enablers for change.

Board #2: Infrastructure, women’s time allocation, and economic development: a multidisciplinary theoretical model.
Pierre-Richard Agénor, PhD and Madina Agénor, MPH

Background: Research shows that infrastructure—namely access to safe water, sanitation, electricity, and transportation—may have a sizable impact on health outcomes in low-income countries. The detrimental effects of poor access to infrastructure on health disproportionately affect women—especially poor women in rural areas—who tend to allocate considerably more time to household production than men. No study has explicitly explored the role that women’s access to infrastructure plays in shaping the relationship between gender and economic development using a multidisciplinary theoretical model that draws on macroeconomics, gender studies, and public health. Methods: This paper uses a three-period, gender-based overlapping generations model to investigate how women’s access to infrastructure affects their time allocation and, in turn, economic development. Results: Greater access to infrastructure can increase the efficiency of women’s time allocated to home production and child rearing activities such that they can dedicate more time to market labor, education, and their own health care. These activities have a positive effect on economic development, as healthier and more educated women can make greater contributions to the economy. Discussion: This paper suggests that investing in women’s health is a productive activity, which could be best achieved by improving their access to infrastructure. While government expenditures on education and health contribute to economic development, public spending on infrastructure may have a greater impact on economic growth as a result of its effects not only on access to education and health services, but also on the efficiency of women’s time allocation.

Board #3: Public health and people with disabilities: where we are and where we need to go.
Dorothy E. Nary, MA and Chiaki Gonda, BGS

People with disabilities, one of the largest minority groups in the U.S., have made significant progress in the last 50 years to promote their civil rights. Passage of legislation such as Americans with Disabilities Act of 1990 has increased the participation of people with disabilities in the mainstream of society. Recent public health efforts, including the Surgeon General’s Call to Action to Improve the Health and Wellness of Persons with Disabilities and Healthy People 2010, have documented the health disparities experienced by this group and set objectives to address them. Additionally, the World Health Organization’s International Classification of Functioning, Disability, and Health [ICF] now recognizes disability as “a universal human experience” and takes in to account the social, and not just the medical, aspects of disability. All of these efforts have contributed to improved opportunity and quality of life for people living with a variety of disabilities. However, people with disabilities remain one of the most obese and sedentary populations in the U.S. and still experience significant barriers to accessing health care, health promotion and wellness services. This presentation will provide a demographic profile of people with disabilities in the U.S., explain the barriers to health and wellness experienced by this group, and describe emerging programs to promote their health.

Board #4: Issues in assessment of “race” among Latinos: implications for public health.
Vincent C. Allen, BA, Christina Lachance, MPH, Britt Rios-Ellis, PhD, MS, and Kimberly Kaphingst, ScD

Measurement of individuals’ race/ethnicity is an integral part of assessing and addressing disparities in health experienced by racial and ethnic minorities. However, the measurement of the social construct of race as it relates to Latinos has been the source of much debate. The unique historical and cultural experiences of Latinos related to race and racism has impacted individuals’ responses to measurement approaches. In particular, the selection of “some other race” in surveys (e.g., by 42% of Latinos in Census 2000) is a critical issue to consider. Meaningful characterization of this growing population is becoming increasingly important; however, data collection methodologies yielding ambiguous responses reveal little about the population. This issue has implications for how health data on Latinos is collected, reported, and interpreted, and to whom resources are allocated. The burden of disparities in health experienced by the Latino community makes the need for a more complete understanding of this population of particular importance. This paper examines Latinos’ selection of “some other race” when asked to classify their race, and how this relates to their historical experience and understanding of their racial identity. For example, research indicates that understandings of race among Latinos differ from the predominant U.S. conceptualizations of this construct, thereby affecting measurement. Data collection methodologies also impact reporting of race. We offer recommendations for measuring race and ethnicity in research and policy settings in ways that have the potential to yield more meaningful data that can be used to address the health needs of Latinos.

Board #5: Reducing disparities in emergency preparedness and response for people with disabilities.
Chiaki Gonda, BGS

Typically, people with disabilities are left out of the disaster preparedness and planning process (White, 2008). Recent research indicates that the majority of emergency managers are not trained in special needs populations, which includes people with disabilities (White, Fox, Rooney & Rowland, 2007). Recent major disaster incidents such as September 11 and Hurricane Katrina, Rita, and Ike have revealed disaster response shortcomings of the public health and emergency management systems to help get people with disabilities out of harm’s way during disaster conditions. This poster will describe key findings and recommendations from the research literature and identify resources and strategies to help reduce disparity for people with disabilities during disaster events or other emergencies.

Board #6: Formulating an evaluation and data collection plan for the Baltimore Cardiovascular Health Disparities Initiative.
Sushila Murthy, MPH, MD (C), Shannon Cosgrove, MHA, and Caroline Fichtenberg, PhD

The Baltimore City Health Department is proposing an Initiative to address cardiovascular disease. Cardiovascular disease is the city’s leading cause of death, the leading cause of a 6-year gap in life expectancy between the City and the state of Maryland, and the top reason for a 20-year range in life expectancy among neighborhoods within the city itself. The Initiative, to be launched July 2009, aims to bring successful community-based public health programs to scale citywide, translating research into practice and distributing resources to communities in need. The Cardiovascular Health Disparities Initiative includes five evidence-based components, each intended for populations that bear unequal burdens of cardiovascular disease: (1) health education through faith institutions – for women over 40, (2) disease management by community health workers – for underserved patients with known disease, (3) blood pressure screening and referral in barbershops – for at-risk men, particularly African American men, (4) Salt Task Force, (5) tobacco control. Each component requires careful data-collection and evaluation to assess overall program success and target improvement efforts. This paper will focus on evaluation of the first three components. Challenges include those of translating research into practice, namely having limited resources to increase the scale of interventions and subsequent data-collection. Additional considerations include choosing indicators to compare with State and national data and collaborating with community-based organizations to determine how evaluation tasks fall within their organizational capacity. This evaluation scheme seeks to make the Initiative sustainable and serve as an example for other large community-based programs aimed at reducing disparities.

Board #7: Walkscore.com: a new methodology to explore associations between neighborhood resources, race, and health.
Mark Brewster, David Hurtado, Sara Olson, and Jessica Yen

In recent years, interest in relationships between neighborhoods, the built environment and health has increased. One result of this has been the creation of Walkscore.com. This website allows users to enter an address and retrieve a ranking between 0 and 100, the Walkscore, by which users can then assess an address’s location-specific accessibility to neighborhood resources such as grocery stores, restaurants, bars, parks, libraries, and schools lying within the address’s one-mile radius. We investigated the association between Walkscore and health indicators for 15 Boston neighborhoods. Significant inverse correlations were found between Walkscore and neighborhood prevalence of overweight/obesity (r=-0.75, p=0.001), hypertension (r=-0.75, p=0.020), and lack of exercise (r=-0.60, p=0.018). Additionally, an inverse correlation was found between Walkscore and the percent of neighborhood population comprised by African-American residents (r=-0.61, p=0.001). No significant relationship was found between Walkscore and other race groups or with the percentage of neighborhood residents living below the federal poverty line. These findings suggest that Walkscore may be a promising tool for researchers and policy makers interested in exploring the relationships between neighborhoods and health. Furthermore, when linked with other tools, the relationship between Walkscore and the percent of neighborhood population comprised by African-American residents introduces new potential to ask and answer, through a historical and spatial lens, integrative questions relating health inequalities, racial segregation, and the built environment. We discuss interpretative considerations in using Walkscore.com for health investigations, and suggest types of data still needed for further research.

Board #8: Individual and neighborhood level predictors of fear: an examination of the effects of violence and social capital at both the individual and neighborhood level.
Erin Richardson, MS

Background: Individual and area level factors are often both important in examining predictors of health. Neighborhood factors are especially important when examining residents’ perceptions of fear and safety. Fear and safety are inextricably linked and when residents are fearful in their neighborhoods, they are at risk for numerous negative health consequences in addition to the ones they are already concerned about with respect to safety. The purpose of this study is to examine the dual influences of experiencing both violence and social capital on both a personal level and a neighborhood level and assessing these influences (as well as other individual and neighborhood level factors) and their effects on residents’ perception of fear and safety in their neighborhoods. Methods: This is a retrospective, cross-sectional analysis using data from the 2003 and 2005 versions of the California Health Interview Survey (CHIS). Individual level factors that will be examined include four main domains with a multitude of factors within each domain. These individual level domains include demographics (e.g., race, ethnicity, sex, age), health services (e.g., health insurance status, unmet health care needs), risk/protective variables (e.g., social capital) and health (e.g., health status, prior victimization). Neighborhood level factors will also be examined and include two main domains. These two domains are physical environment (e.g., recreation facilities, public housing penetration, home ownership, crowding, incivilities) and social environment (e.g., crime, segregation, police presence, neighborhood social capital). These factors are being examined as two levels of influence on individual’s feelings of fear and safety.

Tues, NOV 10, 6:30 pm to 8:00 pm:
Spirit of 1848 Caucus Business Meeting (Session 441.0, PCC 105A)

Come to a working meeting of THE SPIRIT OF 1848 CAUCUS. Our committees focus on the politics of public health data, progressive public health curricula, social history of public health, and networking. Join us in planning future sessions & projects!

posted by Matt Anderson, MD

New issue of Social Medicine (V4N3) Just Published

Social Medicine, our open-access, online academic journal has just published its latest issue. Here is a brief summary of the articles all of which are available for free at www.socialmedicine.info and www.medicinasocial.info (in Spanish).

Children in post-Civil War Nepal singing revoutionary songs

Special Theme: Social Medicine & War

For this special theme issue on Social Medicine & War, Dr. Vic Sidel served as guest editor. His lead editorial (co-authored with Dr. Barry Levy) examines the diversion of resources to war and the preparation for war.

Quoting from their introduction to the three original research articles about war, Drs. Sidel and Levy write:  ”Dr. Andrea Angulo Menasse, a researcher from Mexico City’s Autonomous University, documents the very personal story of how the violence of the Spanish Civil War affected one family. In her case study the trauma suffered by Spanish Republicans is traced through three generations and crosses the Atlantic Ocean as the family moves is exiled in Mexico. Dr. Sachin Ghimire from the Centre of Social Medicine and Community Health of the Jawaharlal Nehru University reports on his fieldwork in Rolpa, Nepal, the district from which the Nepal Civil War (also called the People’s War) originated in 1996. Based on 80 interviews, he documents the difficulties faced by health care workers as they negotiated the sometimes deadly task of remaining in communities where control alternated between Nepalese Special Forces and the Maoist rebels. Finally, Colombian researcher, Carlos Iván Pacheco Sánchez, from the University of Rosario in Bogota, brings an epidemiologist’s tools to examine the impact of the ongoing armed conflict in the border Department of Nariño. His discussion is informed by the current debate over health care in Colombia where a recent Constitutional Court decision has found that the current health care system violates the right to health.”

Closing the Gap: Where are we one year later

In August of 2009, the WHO’s Commission on the Social Determinants of Health issued a bold call to eliminate health disparities within a generation. Three articles in this issue look at what has – and has not – happened in the intervening year. Our second editorial examines the international response to the Commission’s call. José Carlos Escudero explores the meaning of the report for the WHO and underscores the report’s limitations. A detailed critique of the report, along with an alternative approach to addressing health inequities, is offered by Dr. Anne-Emanuelle Birn. Dr. Birn’s critique is especially important for offering important historical background by exploring how Europeans in the 19th century – notably Louis-René Villermé, Edwin Chadwick, and Friedrich Engels – each approached the social disparities that arose during the Industrial Revolution.

The Peckham Experiment

We are also very pleased to publish three classic texts describing the Peckham Experiment, an innovative community center built in England during the Depression. The Pioneer Health Center was designed around the idea of studying (and fostering) what makes people healthy, rather than what makes them sick. Imagine that!

Please visit the journal and explore the breadth, depth and scope of social medicine past and present. Along with some suggestions for the future.

posted by Matt Anderson, MD

The Last Straw! A Board Game on the Social Determinants of Health

We have just learned that The Last Straw! A Board Game on the Social Determinants of Health has been released in an  English/Spanish version [para información en español, veáse abajo].  For readers of the Portal who are not familiar with it, “The Last Straw” is a board game designed to teach about the Social Determinants of Health.

The game was developed in 2004 by Kate Rossiter and Kate Reeve during a health promotion class at the University of Toronto and has won numerous awards.  They designed the game to promote discussion about the social determinants of health, to  help players build empathy with marginalized people and gain awareness of their own social location; and to encourage learning in a fun and supportive environment.

To get a sense of the game, you can watch the training video:

Drs. Rossiter and Reeve have also published two papers about the game:

Rossiter, K., Reeve, K.  “The Last Straw! A Participatory Education Tool About the Social Determinants of Health.” Progress in Community Health Partnerships: Research, Education, and Action. 2(2): 137-144. 2008.

Reeve, K. Rossiter, K., Risdon, C. “Board Game on the Social Determinants of Health.” Medical Education. 42(11): 1125-6. 2008.

The Last Straw website also contains a list of resources for teaching about the social determinants of health.

posted by Matt Anderson, MD

___________________

¡La gota que colmó el vaso! es una herramienta pedagógica divertida y apasionante sobre los determinantes sociales de la salud.

*Para adquirir ¡La gota que colmó el vaso! puede contactar en inglés solamente a **sales@thelaststraw.ca* <sales@thelaststraw.ca>* o llamar en
inglés a Michael Jackel en Fernwood Books al 416-703-3598.*

El juego tiene tres objetivos: • promover la discusión sobre los determinantes sociales de la salud; • ayudar a los jugadores a desarrollar empatía con las personas marginadas y a tomar conciencia de su propia posición social; • estimular el aprendizaje en un entorno divertido y de apoyo.

De acuerdo con las investigaciones actuales sobre los determinantes sociales de la salud, la situación socioeconómica es uno de los principales
determinantes de la salud en este juego, tanto como la raza, el género, la orientación sexual y otros factores.

La retroalimentación demuestra constantemente que los jugadores adquieren una mejor comprensión de los determinantes sociales de la salud y de las
interacciones entre diversas fuerzas a nivel comunitario e individual. Tanto los jugadores como los facilitadores (“Maestros de Juego”) afirman que con
este juego se divierten mucho.

También hemos desarrollado un manual de capacitación y un vídeo en inglés para ayudar a los Maestros de Juego a aprovechar el juego al máximo.

Social Medicine Volume 4 Number 2: Economic Crisis, Social Determinants, Participation & more

We have just published a new issue of Social Medicine/Medicina Social, our bilingual, online journal.  It is available in both English and Spanish.  Our 13th issue touches on several important issues in world health including the current economic crisis and the WHO Commission’s on the Social Determinants of Health.  And, of course, the stories of activists like the young US students (shown below) studying medicine at the Latin American Medical School (ELAM) in Havana.  They will be traveling in the Southwest US this summer to discuss their experiences with the American Indian community:

The Economic Crisis and Public Health

Barry S Levy, Victor Sidel

The current global economic crisis seriously threatens the health of the public. Challenges include increases in malnutrition; homelessness and inadequate housing; unemployment; substance abuse, depression, and other mental health problems; mortality; child health problems; violence; environmental and occupational health problems; and social injustice and violation of human rights; as well as decreased availability, accessibility, and affordability of quality medical and dental care. Health professionals can respond by promoting surveillance and documentation of human needs, reassessing public health priorities, educating the public and policymakers about health problems worsened by the economic crisis, advocating for sound policies and programs to address these problems, and directly providing necessary programs and services.  Full Text: PDF

An Interview with Sir Michael Marmot

The Editors

In August of 2008 the WHO Commission on the Social Determinants of Health concluded its work with the publication of a report entitled: “Closing the gap in a generation: Health equity through action on the social determinants of health.” The Commission’s chair, Sir Michael Marmot, was kind enough to answer our questions about the Commission’s recommendations. This interview was conducted by email in May of this yea

Participation and empowerment in Primary Health Care: from Alma Ata to the era of globalization

Pol De Vos, Geraldine Malaise, Wim De Ceukelaire, Denis Perez, Pierre Lefèvre, Patrick Van der Stuyft

With the 1978 Alma Ata declaration, community participation was brought to the fore as a key component of primary health care. This paper describes how the concepts of people’s participation and empowerment evolved throughout the last three decades and how these evolutions are linked with the global changing socio-economic context.

Latin American Social Medicine and the Report of the WHO Commission on Social Determinants of Health

RAFAEL GONZALEZ GUZMAN

In October 2008 the Latin American Social Medicine Association (ALAMES) organized an international workshop entitled “The Social Determinants of Health.” Representatives of ALAMES’ seven regions participated in discussions of the various consultative papers prepared by the working groups of the WHO Commission on the Social Determinants of Health as well as the Commission’s final report. The workshop considered how ALAMES should respond to the work of the Commission. In this paper we summarize the main points outlined in the position paper prepared by the Organizing Committee1 as well as a synopsis of the main contributions made by each of the workshop’s study sections.  Full Text: PDF

For the full Table of Contents visit: http://journals.sfu.ca/socialmedicine/index.php/socialmedicine/issue/view/38/showToc

posted by Matt Anderson, MD

Feast or Famine at Social Medicine Rounds

On April 28^th, 2009 Social Medicine Rounds hosted four New York City food activists in a session entitled: “Feast or Famine: Building an Oasis in the Food Desert.”  This rounds was arranged by Drs. Victoria Mayer and Vanessa Pratomo and is part of a larger series organized by the Public Health Association of New York City (PHANYC).  [See our previous posting: Feast and Famine: Obesity, Diabetes and Hunger in New York City.]

Joel Berg, Triada Stampas, Debi Lomax, Zena Nelson, Drs. Mayer & Pratomo

As clinicians we daily see patients whose health is deeply affected by nutrition.  Counseling patients on diet often seems a frustrating affair and there is scant evidence that it does much good.  We were interested in a better understanding the politics of food and in learning about what local  food activists were up to.  Our invited panel included Joel Berg of the NYC Coalition Against Hunger, Debi Lomax of the Bronx District Public Health Office, Zena Nelson of the South Bronx Food Coop, and Triada Stampas from the Food Bank for New York City.

The paradoxical link between food insecurity and obesity

Joel Berg is the Executive Director of the New York City Coalition Against Hunger and author of the recently published All You Can Eat: How Hungry is America. He began by emphasizing the lack of nutrition education in medical schools, arguing that nutrition should be the centerpiece of public health.  He saw hunger and obesity not as separate problems but rather as “flip sides of the malnutrition coin.”  He pointed out that currently 25 million Americans (about 8% of the population) use food pantries and soup kitchens.  Here in New York City an estimated 1.3 million people (about 16% of the 8.2 million New Yorkers) are living in food insecure homes.  The poor are often accused of not knowing how to budget, shop and cook.  But Mr. Berg pointed out that working class people often don’t have access to affordable, good food, a point reiterated by the other three speakers   Faced with limited cash, people often choose unhealthier foods because their high fat content. Time constraints – due to work schedules – further limit the ability of working class families to shop and cook.

Mr. Berg argued that good nutrition is a three legged stool based on affordability, proximity and education.  The way to make good food more affordable was the increase wages, expand access to WIC and encourage our kids to take advantage of food offered in the schools (breakfasts, lunch, afterschool meals and summer breakfasts).  Making sure that school food is healthy is also an area of intense activism. While New York City has recently banned the sale of soda in the schools, highly sugared drinks like Snapple continue to be sold.

Farmers’ Markets in the Bronx

Debbie Lomax, a Program Officer for the South Bronx District Public Health Office of NYC Department of Health, then discussed the DOH Farmers’ Market Program.  Quoting their program booklet:  “The Farmers’ Market Program encourages fruit and vegetable consumption by promoting farmers’ markets in the South Bronx.  There are currently 11 markets in the area. The DPHO publicizes these markets to community residents and health care providers, by giving out “Health Bucks” – $2.00 vouchers redeemable at farmers’ markets for the purchase of fruits and vegetables.”

A complete description of this program and a list of current Farmers’ Markets can be downloaded from this link. More information on Healthy Bucks can be found at this link.

A Food Coop grows in the Bronx

Zeena Nelson is one of the founders of the South Bronx Food Coop.  Her interest in food was sparked by her personal difficulties finding good food in her South Bronx community.  She had studied business at Fordham University but was unenthusiastic about working for corporate America. She was pushed into food activism when a friend died of complications of massive obesity.  What, she wondered, were the economics behind the fact that certain neighborhoods don’t have good food available? She obtained a $20,000 starter grant from Merill-Lynch to set up a small food coop.  The coop now has 155 members and operates a small store on Third Avenue   Members of the cooperative are a diverse group about ½ of whom are from the South Bronx.  The cooperative provides a variety of services including cooking and yoga classes.   The Cooperative has plans to create a commercial hydroponic farm inside of a local building.

[For a fascinating look at the world of urban agriculture in New York City, visit Kerry Trueman's Retrovore.com.]

… as do the soup kitchens

Finally, Triada Stampas shared her work at the Food Bank for New York City.  The Food Bank started 26 years ago in a big warehouse located in the Hunts Point food market in the South Bronx.  The Bank initially supplied food to a handful of sites providing “emergency food.’  Sadly, it currently supplies some 1200 soup kitchens and pantries (yes, that’s 1200 sites) located throughout the City. .  Ms. Stampas noted that such a network simply was not needed in the 1970’s.

The food at the bank comes from various sources.  The government – federal, state and city – provides some.    Feeding America, a national umbrella for food banks, provides food largely donated by corporations. The bank itself raises funds to purchase food.  The Bank also conducts research on who uses emergency food.  By their estimates there are 4 million New Yorkers (nearly half the population) who have difficulty accessing affordable food.  Ms. Stampas noted that the term “emergency food” was really a misnomer. For many people emergency food  represented subsistence food.  She pointed out, for example, that 80% of  families receiving food stamps run out of food before the month is over.  She spoke about understanding nutrition as a function of the “food environment.”  Bronx residents, according to a recent study by the Marist Institute, have the greatest difficulty finding affordable food in the city.

Ms. Stampas had some specific suggestions for clinicians. She stressed that it was important to talk with patients about what they eat, where they shop for food, and how they afford the food they buy.  She pointed us to a food bank locator on the web that could be used when our patients needed food. She signalled the importance of political advocacy to improve food stamp benefits and increase the Earned Income Tax Credit.

Clinicians as advocates

During the question and answer period a number of an additional areas for activism were suggested.  Hospitals need to promote healthy eating for staff, patients and visitors.  Political support is needed right now for the school meals program and WIC both of which are up for authorization in Congress. In New York State a Healthy Schools Law is being considered in Albany.  The speakers highlighted the importance of physician voices in support of these programs.

Posted by Matt Anderson, MD

Blame NAFTA for swine flu, experts say: Lax farming rules under free trade deal create breeding ground for virus, environmentalists argue

The news clip below, from the Toronto Star website, is food for thought for social medicine practitioners. It shows very compellingly the damaging effects of lax and unjust labor policies and how these effects can spread to countries where labor policies are less lax. Clearly, viruses do not recognize political borders! For a very thorough and complete swine flu coverage click here.

by Linda Diebel, Staff Reporter at the Toronto Star

MEXICO CITY-Sewage-filled lagoons at a pig farm in eastern Mexico – a product of the North American free trade deal – are suspected of creating ground zero conditions for swine flu in this country.

Environmentalists argue lax regulations in the factory farming that boomed in Mexico right after the 1994 North American Free Trade Agreement with Canada and the U.S. are making people sick – and not just with swine flu.

“You might call this the ‘NAFTA flu,’” said Rick Arnold, co-ordinator of Common Frontiers, a Canadian coalition focusing on Latin America and issues of economic integration.

He argues multinationals are getting away with dire conditions not allowed north of the border.

Environmental groups three years ago began protesting against operations at the Carroll Farms in Veracruz, jointly operated by U.S. pork giant Smithfield Farms.

The first confirmed case of swine flu originated with a 5-year-old boy from the town of La Gloria, near the farm. He recovered.

Medical officials have not pinpointed where the outbreak began.

And from its Virginia headquarters, Smithfield officials insist there is no evidence linking their operations to the disease.

Smithfield Farms, the world’s largest pork producer with $12 billion in annual sales, opened Carroll Farms in 1994, calling it a “joint venture.

At home, the company was fined $12.6 million (U.S.) in 1997 after the U.S. Environmental Protection Agency disclosed it was dumping raw pig sewage into a river flowing into Chesapeake Bay.

The health ministry, which earlier said 168 people were believed killed by swine flu in Mexico, yesterday would confirm only 12 of those deaths as being from swine flu and would not say how many more cases were suspected.

The air in Mexico City, once called the “most polluted” by the World Health Organization, is loaded with human fecal matter, gases, dust and other toxic materials.

“The pollution affects our eyes, throats and lungs,” said Dr. Erendira Gallardo Lobera, a general practitioner. She said the Mexican government should take stronger measures to ensure residents of the capital aren’t breathing in rat and dog feces with their oxygen.

While Mexicans continue to wear masks and stay indoors in a country virtually shut down, people say the government should be more forthcoming with information.

“I think the government isn’t giving us the correct statistics about infected cases,” said restaurant employee Jose Gutierrez Hernandez. “I fear there’s not enough medicine to control this outbreak and there is no vaccine against swine flu.”

President Felipe Calderon promised his officials would provide timely information, adding as a “parent and as a person, there is nothing more important to me than the life and health of the Mexican people.”

From the Mexican embassy in Ottawa, spokesperson Alberto Lozano Merino said Mexican authorities are not concerned with pig farm operations near the suspected epicentre of the swine flu outbreak. Authorities acted quickly to send Veracruz samples to the Centers for Disease Control and Prevention in Atlanta, Ga., and have “followed every regulation and protocol.”

However, the Veracruz newspaper La Marcha, as well as the Mexico City daily, La Jornada, reported widespread cases of people falling ill near the pig farm in March.

Several local groups argue the farms should be closed pending extensive environmental and health reviews of an operation that raises 950,000 pigs a year and doesn’t have a sewage treatment plant.

In a 2006 article on Smithfield’s Virginia operations, Rolling Stone reported: “(The) pigs live by the hundreds or thousands in warehouse-like barns, in rows of wall-to-wall pens (and) trample each other to death.

“The floors are slatted to allow excrement to fall into a catchment pit under the pens, but many things besides excrement can wind up in the pits: afterbirths, piglets accidentally crushed by their mothers, old batteries, broken bottles of insecticide, antibiotic syringes, stillborn pigs …”

The article said the “pipes remain closed until enough sewage accumulates in the pits to create good expulsion pressure; then the pipes are opened and everything bursts out into a large holding pond.”

Yesterday, La Jornada ran a photo of a large waste-filled lagoon at Carroll Farms in Veracruz. A caption under the photo says farm officials stress the pork waste flowing into the lagoon generates “absolutely no type of contamination.”

C. Larry Pope, president and CEO of Smithfield Farms, sent a letter yesterday assuring all employees the company is doing everything possible “and will continue to do so (to keep) our workers and pigs healthy.”

The Debate over Health and Mass Privatization in post-Communist Europe

In January of this year the Lancet published an article entitled Mass privatisation and the post-communist mortality crisis: a cross-national analysis written by David Stuckler and Lawrence King of Oxford University’s Department of Sociology and Martin McKee of the London School of Hygiene and Tropical Health. The article concluded that the adoption of mass privatization (a component of “shock therapy”) during the transition from Soviet-style communism was associated with increased mortality among working age men. This finding adds to the ongoing discussion on the health impacts of privatization and more generally to the study of the health effects of economic policy.  [A prior posting on the portal discussed Oxfam's recent report, Blind Optimism which examined privatization in health care.]

The Context

The transition from Soviet communism to capitalism after the fall of the Berlin Wall in 1989 was associated with increases in mortality in certain countries, particularly those of the former Soviet Union.  In a 2004 British Medical Journal editorial Dr. McKee and Kristina Fischer summarized the situation:

Life expectancy at birth is now lower in the transition countries than that in western Europe. Although in the 1960s it was slightly higher in former East Germany than in former West Germany, by the 1970s the numbers reversed and the gap has been widening ever since. In 2000, life expectancy at birth was almost 12 years less in the countries of the former Soviet Union than in western Europe, and it is continuing to decline, making the former Soviet Union one of only two regions in the world where life expectancy is declining, the other being sub-Saharan Africa.  But in other post-communist countries life expectancy is generally improving.

The health consequences of the transition were, thus, different in different countries.  Life expectancy decreases were particularly marked in Russia while in Croatia and Poland life expectancy increased.  What accounted for these differences between countries?

What the authors did

Stuckler and his colleagues set out to understand whether economic policies could explain the differing health experiences of the transition countries. They distinguished between countries who adopted “shock therapy” (“liberalisation of prices and trade to allow markets to re-allocate resources, stabilisation programmes to suppress inflation, and mass privatisation of state-owned enterprises to create appropriate incentives”) and those that adopted more gradualist approaches.  Russia, for example, instituted shock therapy in the early 1990’s at the urgings of Harvard economist Jeffrey Sachs.

The authors suspected mass privatization would increase unemployment; unemployment has a variety of negative health effects.  If unemployment increased mortality, the effect might be seen in working age men.  The authors created a statistical model to explain the intra-national differences in mortality rates for men aged 15 to 59.  In their statistical model they controled for a variety of variables (such as whether a country was at war or changes in trade in policies). To examine the effect of privatization they used two different mesasures;  one was a measure that they developed on their own and the other was a ranking system from the European Bank for Reconstruction and Development (EBRD).  Using a technique called logistic regression, they concluded that “Mass privatisation programmes were associated with an increase in short-term adult male mortality rates of 12·8%.”  They found some evidence that unemployment mediated this increase and that participation in civic organizations decreased it.

The authors drew the following policy implications from their conclusions:

“Great caution should be taken when macroeconomic policies seek radically to overhaul the economy without considering potential effects on the population’s health. As variants of rapid reform policies are being debated in China, India, Egypt, and several other developing and middle-income countries—including Iraq—which are just beginning to privatise their large state-owned sectors, the lessons from the transitions from communism should be kept in mind.”

The Response

Within days of the Lancet report, Dr. Jeffrey Sachs published an angry response (“‘Shock therapy’ had no adverse effect on life expectancy in eastern Europe”)  in the Financial Times.  He cited the increased in life expectancy in Poland as evidence that shock therapy did not increase mortality and went on to implicate non-economic factors (such as corruption and the poor Soviet diet) for what happened in Russia.  (Stucker et. al’s response to Sachs was published by the Financial Times on January 22nd.)

The Lancet itself published two letters to the editor (and a response) on April 11.

One letter by Italian researchers Giorgio Tamburlini and Adriano Cattaneo looked at different rates of infant mortality decrease (from 1990-2005) in Moldova and Georgia, countries with differing degrees of health care privatization.  In Moldova, which was transiting to a national health insurance system, infant mortality rates dropped by 54%, while in Georgia, where the health care system was increasingly privatized, infant mortality rates decreased by only 4%.

The other letter by John S. Earle, of the Upjohn Institute for Employment Research,  used data from individual firms in four post-communist countries to argue that privatization did not result in job cuts, a finding that contradicted that of the Lancet authors and which they described in their response as “counter-intuitive.”  Earle’s argument is presented in fuller form in this link.

Commentary

Stuckler’s paper was accompanied by a Lancet editorial (Societal Transition and Health) written by Martin Bobak and Michael Marmot of University College London.  While supporting the authors conclusions, they note:

“Even with the use of an ingenious design, such as that adopted by Stuckler and colleagues, pre-existing societal characteristics cannot be taken into account. This flaw is not a criticism, but rather an illustration of the difficulties faced by investigators who wish to disentangle the effects of different factors that act at the societal level.”

There are inherent limitations in the study of historical events which are by their nature unique and unreproducible.  These difficulties are compounded when one studies different countries;  statistical models really cannot control for all differences.  The fact that Poland adopted a gradualist approach to privatization makes Poland intrinsically different from Russia where the political class adopted a more radical approach.

Nonetheless, it would be hard to argue that shock therapy did not have negative health effects.  It is unfortunate that the Dr. Sachs is so closely associated with this policy that the debate has a personal tone.  Clearly, privatization (often forced) of social institutions is a policy that has had broad support amongst those who dictate global economic policy.

The conclusion of the Lancet authors – that radical macroeconomic policies need to be considered in light of their health consequences – should be pretty uncontroversial.  If it is controversial we should wonder why.

posted by Matt Anderson, MD

American corporate capitalism and social determinants of health

The documentary “Capitalism hits the fan” (click here for a preview) offers a good analysis of the global financial crisis and argues that the stimulus package, bailouts, and calls for regulation will not work unless more fundamental changes, including, yet not limited to,  reversing the downward trends in wages over the last three decades, are made.

If, as social medicine practitioners, we believe that living conditions are extremely relevant to health, and in turn depend on social, economic, public health and political policies, the documentary gives us a way to understand, and as the preveiw points out, “react to the unraveling economic crisis”.

Corporate capitalism: A threat to public health?

The latest economic downturn and the collapse of global finance are eroding the very foundations of human health: millions are losing their homes, their means of livelihood, their health care and their dream of an education. And while most analysts agree that, collectively, the productivity of American workers has grown dramatically over the last thirty years, wages have remained stubbornly stagnant, at the same time as wealth is increasingly concentrated in fewer hands (which, as Professor William Domhoff points out, indicates increasing concentration of power). Clearly, the huge wealth created by the world’s most powerful “capitalist democracy” has not been equitably distributed.

So it comes to no surprise that many are questioning the “benefits” of global capitalist practices (whose shortcomings are masterfully described in this old but remarkably current article by Mark Weisbrot from the Center for Economic and Policy Research), and indeed, the very notion that, as we are often told, “capitalism is good for democracy”, assuming of course, democracy as a form of political organization concerned with, and able to, improve the wellbeing of the ordinary people who give it its legitimacy.

Michael Perenti, a long-time political analyst, argues that unless the state saves capitalism from itself, for instance, through equitable economic and social policies, as seen in European social democracies, free-market capitalism is doomed to collapse under the “seeds of its own destruction”, much like Karl Marx argued close to one hundred and fifty years ago, and Friedrich Engels, Marx’s intellectual partner, so very well described in his masterpiece “The conditions of the working class in England” (click here for an excerpt), arguably among the classics of public health..

Below go fragments of Perenti’s recently published article (click here for the full article), where he lays out his thesis, and an interview with Amy Goodman, where he discusses the bailout of major financial institutions (essentially, how the money is being used), and what this implies for what the health professions know as the social determinants of health.

…..

…..

“Let us consider democracy first. In the United States we hear that capitalism is wedded to democracy, hence the phrase, “capitalist democracies.” In fact, throughout our history there has been a largely antagonistic relationship between democracy and capital concentration. Some eighty  years ago Supreme Court Justice Louis Brandeis commented, “We can have democracy in this country, or we can have great wealth concentrated in the hands of a few, but we can’t have both.” Moneyed interests have been opponents not proponents of democracy.

…..

The conservative plutocracy also seeks to rollback democracy’s social gains, such as public education, affordable housing, health care, collective bargaining, a living wage, safe work conditions, a non-toxic sustainable environment; the right to privacy, the separation of church and state, freedom from compulsory pregnancy, and the right to marry any consenting adult of one’s own choosing.

…..

Consider the United States. In the last eight years alone, while vast fortunes accrued at record rates, an additional six million Americans sank below the poverty level; median family income declined by over $2,000; consumer debt more than doubled; over seven million Americans lost their health insurance, and more than four million lost their pensions; meanwhile homelessness increased and housing foreclosures reached pandemic levels.

…..

About a century ago, US labor leader Eugene Victor Debs was thrown into jail during a strike. Sitting in his cell he could not escape the conclusion that in disputes between two private interests, capital and labor, the state was not a neutral arbiter. The force of the state–with its police, militia, courts, and laws-was unequivocally on the side of the company bosses. From this, Debs concluded that capitalism was not just an economic system but an entire social order, one that rigged the rules of democracy to favor the moneybags.

…..

The immense inequality in economic power that exists in our capitalist society translates into a formidable inequality of political power, which makes it all the more difficult to impose democratic regulations.

…..

If the paladins of Corporate America want to know what really threatens “our way of life,” it is their way of life, their boundless way of pilfering their own system, destroying the very foundation on which they stand, the very community on which they so lavishly feed.

Housing is good for your health: Action alert to stop foreclosures

Because shelter is a basic human need, and housing a critical social determinant of health, policy makers need to take bankrupcty reform seriously, to prevent millions of Americans from losing their homes to foreclosure.

As CREDO, a virtual grassroots movement has put it, “billions upon billions of dollars have been given to the banking industry” yet judges are yet to be given the power to restructure mortgage loans. CREDO also warns that “the banking industry has spent an exorbitant amount of money lobbying Congress to keep judges from getting that power”. To sign their petition click here.

For those interested in a deeper understanding of these issues, in “Matters of Principal”, op-ed contributors John D. Geanakoplos and Susan P. Koniak explain (in terms that a non-economist like me can understand) why the staggering amount of 275 billion dollars that President Obama’s stimulus plan set aside presumably to address the housing crisis is unlikely to work – that is, for homeowners. Because if you are a lender the story is different, and not a bad one at all — yet another instance of “tails I win, heads you lose”.

The long version is really worth reading, but the short version is that while with the president’s plan homeowners may see the interest rates on their mortgages, hence their monthly payments, decrease, too many among them will still be “under the water”, i.e., owing more than what their house is worth at current market values.

Which in turn means that they will have very little equity (the writers offer an example with very simple numbers), if at all. Which means that after a few years, while the lenders, courtesy of taxpayers, will have recovered at least partly what they otherwise would have lost for engaging in reckless lending, many homeowners are still likely to default, and face homelessness.

Geanakoplos and Koniak argue that only bankruptcy reform can work, hence the timeliness of CREDO’s action alert. Bankrupcy reform allows for a reduction of the principal, and gives homeowners equity – and a real stake at keeping their homes – while costing taxpayers very little. Of course in this alternative plan lenders have to live with losing some money. But hey, was this plan not about homeowners, not lenders?

posted by Claudia Chaufan