Jonathan Purtle, MPH, Doctoral candidate and Research Associate, Center for Nonviolence and Social Justice, Drexel University
Why do we die? The question is existential, scientific, and spiritual at the very least. It’s also bureaucratic. Like voter registration cards and driver’s licenses, death certificates relegate the cause of our physical demise to a discrete category that becomes a single data point in a sea of statistical information. And they are vitally important to the public’s health.
In “Final Forms,” an excellent article in the April 7 issue of The New Yorker, Kathryn Schulz tells the story of the death certificate: its history, its public health significance, its shortcomings.
Schulz traces the origins of the modern death certificate back to 1512. In London, Bills of Mortality were first issued to track the number of people who died from the plague, in addition to the number succumbing to non-plague causes. The Bills included no information about individual decedents, such as their name or what exactly killed them (other than the plague), and were only issued sporadically after the terror of the Black Death subsided. Things changed, however, in 1629 when King James I mandated that the Bills be issued on a regular basis, capture every death, and its cause. Years later, an actuarially-oriented haberdasher named John Gaunt reviewed 20 years worth of Bills and teased out 81 distinct causes of death across the four categories: chronic diseases, epidemic disease, conditions that killed children, and injuries.
Jonathan Purtle, MPH, Doctoral candidate and Research Associate, Center for Nonviolence and Social Justice, Drexel UniversityFirst in a series of posts about what is being done to address trauma and toxic stress in the city.
Four years ago, on a train from Philadelphia to Washington, Sandra Bloom told me about the Adverse Childhood Experiences (ACE) Study. I hadn’t heard of it, and was astounded to learn about strong connections it found between exposure to trauma and toxic stress in childhood, and experiencing behavioral, social, emotional, and health problems as an adult. I told almost everyone I knew. I circulated the study’s publications among my public health peers. Hardly any of them had heard of it in 2011, when I wrote the first of several related posts.
On Thursday, I sat with more than 350 Philadelphians at WHHY's studios as the study was discussed at a sold-out symposium entitled “Children and Toxic Stress: A Public Health Response for Philadelphia’s Children and Families.” Awareness about the ACE Study (first findgs were published in 1998) and its implications has spread rapidly over the past few years. And Philadelphia, in the words of Arthur Evans, commissioner of the city's Department of Behavioral Health and Intellectual disAbility Services, has been the “epicenter” of knowledge dissemination. “Philadelphia is the only city where only a few hands pop up when I ask how many people have not heard of the ACE Study,” said Martha Davis, a new program officer at the Robert Wood Johnson Foundation who until recently headed the local Institute for Safe Families. A brief video of her remarks on building resilience is here.
Jonathan Purtle, MPH, Doctoral candidate and Research Associate, Center for Nonviolence and Social Justice, Drexel University
It’s not just military veterans who develop post-traumatic stress disorder. As described in a previous post, what’s known today as PTSD has been observed in people who experienced traumatic events for centuries if not millennia. One relatively common event that can cause PTSD is a serious injury, like from a car accident or a gunshot wound. There are a lot of those. A study of 2,707 surgical trauma patients from across the United States several years ago found that more than a fifth had PTSD one year after their injury.
So why isn’t PTSD screening and referral to treatment the standard of care in trauma centers? Lois Beckett and colleagues have set out to answer just that question. In a group of articles for ProPublica, the nonprofit investigative journalism site, they examine why trauma centers, of which there are quite a few locally, don’t sufficiently address the mental health consequences of traumatic injuries and the burden of PTSD among civilian populations – with a detailed look at the issue in Philadelphia (deep into the piece).
Their work, which is part of a larger series on guns, includes a survey of personnel at 21 trauma centers across the country that asks what, if anything, they do to address PTSD among their patients. The responses – Temple University Hospital said it is developing a program – are posted.
The Olympics have brought attention and scrutiny to Russia’s policies on homosexuality for infringing upon the human rights of its citizens and visitors. But could the the country's position on gays and lesbians also pose a hazard to the health of its citizens?
As we’ve written about in the past, prejudice harms the health of targeted minority populations (sexual and otherwise) through multiple pathways. The results of a recent study in the American Journal of Public Health, however, suggest that anti-gay prejudice might harm those who harbor it—not just its targets.
The study’s authors, from Columbia and the University of Nebraska, used data from the General Social Survey and National Death Index to test the hypothesis that heterosexuals with high levels of anti-gay prejudice have greater mortality risk than people with low levels. The General Social Survey has asked questions of nationally representative samples of adults in the United States since 1972 and is considered a primary source of data on social trends. Respondents have been asked questions about their sexual orientation and opinions on homosexuality since 1988. The researchers used the following four questions to categorize the 20,226 respondents as having “high” or ”low” levels of anti-gay prejudice.
- “If some people in your community suggested that a book in favor of homosexuality should be taken out of your public library, would you favor removing this book, or not?”
- “Should a man who admits that he is a homosexual be allowed to teach in a college or university, or not?”
- “Suppose a man who admits that he is a homosexual wanted to make a speech in your community. Should he be allowed to speak, or not?”
- “Do you think that sexual relations between two adults of the same sex is always wrong, almost always wrong, wrong only sometimes, or not wrong at all?”
A law is only as good as the ability to enforce it. Drunk driving is major cause of disability and premature mortality in the U.S., with the Centers for Disease Control and Prevention estimating that alcohol-impaired driving is responsible for about 10,000 deaths annually. For this reason, driving with a blood alcohol concentration of 0.08 or higher is illegal throughout the country, with laws and penalties varying from state to state. All states, for example, have laws requiring judges to mandate that some or all convicted drunk drivers install in their vehicles ignition interlocks, which analyze a driver's breath and disables the engine if alcohol is detected. Pennsylvania mandates them for repeat convictions; New Jersey does the same, and adds drivers with high blood alcohol content (0.15 and above).
These laws would be of little value, however—and ignition interlocks wouldn’t exist— if there wasn’t an efficient and effective way to measure drunkenness. Enter a brief history of the Breathalyzer—a tool of public health.
While the observation that people carry alcohol on their breath is probably as old as booze itself, the scientific study of how to detect intoxication in the U.S. appears to have developed out of necessity: how to enforce prohibition laws during the roaring 20s, when moonshine flowed and fast cars were cheap.
By mid-January, a pile of “Year in Review” magazines has accumulated beneath my coffee table. These dog-eared retrospectives all contain stories of a similar sort: famous people who died in 2013. The close of the calendar is a fitting time to reflect on icons who have departed, but what about the new arrivals? While we can’t predict the coming achievements of babies born in 2013, statistics on life expectancy at birth allow us to project on average how long they’ll live—estimates that vary dramatically according to the social, economic, and political circumstances they’re born into.
Life expectancy at birth is defined by the World Health Organization as the “average number of years that a newborn is expected to live if current mortality rates continue to apply.” This means that the average age of death in the population a baby is born into is equivalent to the number of years they can be expected to live. This estimate, of course, does not account for future changes that might impact mortality rates during their lives (e.g., societal improvements or medical advances that could make them live longer, or climate changes or pandemics that could make them live shorter). Life expectancy in the United States has improved dramatically over the past century—from 47.3 years in 1900 to 78.1 in 2008—due largely to public health advances such as sanitation, indoor plumbing, better working conditions, and immunizations.
Globally, it varies dramatically. Statistics from The World Bank show that life expectancy at birth is 45 years for a baby born in Sierra Leone and 82 years in Japan or Switzerland. Money explains some, but not all, of the difference. The U.S. is among the richest countries in the world and spends a substantially greater portion of its gross domestic product on health care than do other members of the Organization for Economic Cooperation and Development (OECD)—17.9 percent in 2011; the Netherlands was second-highest at 11 percent— but ranks 17th worldwide male life expectancy at birth and 16th for female. As outlined in a recent Institute of Medicine report, issues such as early childhood poverty, built environments that promote automobile use and discourage physical activity, firearm deaths, comparatively limited access to primary care, and vast inequities in income and education all contribute to the nation’s lackluster showing.
I stayed up late working the other night (no, not New Year’s Eve) and didn’t sleep enough. The next day I felt irritable and had trouble concentrating as a result. Can you relate? In some ways, sleep deprivation is a celebrated American ideal: we admire those who burn the “midnight oil” and “candle at both ends.” But it’s also a major public health problem that is rarely discussed.
The brain needs sleep to keep the body alive. Lab rats, for example, typically live for two to three years, but research has found that they survive a mere five weeks when deprived of REM sleep - and only three weeks when completely sleep-deprived. Humans are different than lab rats in many respects, but pretty similar when it comes to the importance of sleep.
Inadequate sleep, in quantity of hours or quality of depth, affects how well our bodies function and how good we feel. There is a strong association between poor sleep and depression, with about 90 percent of people diagnosed with the disorder reporting sleep problems. While it’s not clear whether depression causes poor sleep or if poor sleep causes depression (it’s probably a bit of both), new research is finding that effective sleep therapy can lead to reductions in depressive symptoms, suggesting that poor sleep might be the primary cause in some cases. An estimated 50 to 80 percent of people receiving mental health services have a chronic sleep problem, compared to 10 to 18 percent of adults in the general U.S. population.
I brought this picture of a triangle to Thanksgiving this year. It helped me explain what public health is to distant relatives who don’t understand what I’m going to school for. I struggle to articulate it every year, so this time I relied on the aid of a diagram developed by a seasoned professional: Dr. Thomas Frieden, director of the U.S. Centers for Disease Control and Prevention.
The triangle is actually a pyramid. It's called The Health Impact Pyramid. The pyramid is hierarchical and has five tiers. The most impactful types of public health interventions are at the bottom, the least impactful are at the top. Accompany me on a descent down the pyramid, similar to what I served to relatives on Thanksgiving.
At the tip of the pyramid are educational interventions. These are generally the most common, but least effective, types of public health interventions. Examples of note include: D.A.R.E., graphic cigarette warning labels (if they were allowed), calorie counts on menus, and the other, more famous, three dimensional triangle in public health—the food pyramid. Educational interventions are based on the idea that people will do healthy things if they know what’s good for them and what’s not. While these interventions work for some people, they don’t for most in the absence of supporting environmental changes. Even if little Johnny learns that exercise is good for him, he’s unlikely to run and play if the park is ridden with broken glass and scary people selling drugs. Video games will probably remain a safer, but more sedentary, activity.