We’ve been covering the news on recent vaping-related lung injuries, and a lot has happened since our last video. Time for an update!
We’ve been covering the news on recent vaping-related lung injuries, and a lot has happened since our last video. Time for an update!
The health troubles we’re seeing now — especially among young people — will continue to strain the system for years and even decades to come.
The big picture: Rising obesity rates now will translate into rising rates of type 2 diabetes and heart disease. The costs of the opioid crisis will continue to mount even after the acute crisis ends. And all of this will strain what’s already the most expensive health care system in the world.
The United States population is 327 million and there are 393 million guns in this country. The issue of guns and gun control remains one of the nation’s most divisive.
As the Los Angeles Times explains in a recent editorial, “to truly address gun violence, we need to view it through a public health lens — one that reframes the issue as a preventable disease that can be cured with the help of all community members.”
The American Public Health Association (APHA) shared recently that the U.S. has the dubious distinction of “outpacing” any other country with a gun violence burden. Highly publicized statistics vary from source to source, but they do bear repeating, beginning with the fact that:
including Australia, France, Italy, Spain and the United Kingdom — occur in the U.S.
The Gun Violence Archive stays up to date on this year’s sobering victim numbers, already standing at:
Total incidents: 36,390
Mass shooting: 268
Ways but No Will
Having dedicated himself to the science of gun violence, health policy professor David Hemenway, Ph.D., of the Harvard T. H. Chan School of Public Health says we’re all watching too much media where “guns are the solution to so many problems. The good guy with the gun is the big hero.”
In real life, guns are not solutions to problems. The myth is imposed early and continues to be perpetuated. Children are exposed to 90 percent of movies, 68 percent of video games and 60 percent of shows that include violence, Common Sense Media said six years ago. Current numbers are surely much higher.
Dr. Hemenway also balks at the old “we’ll be able to protect ourselves when that intruder comes into our space” argument. It takes lots of training, repetition and practicing, over and over, to do the right thing right, he says, and most don’t have time or resources to get that — right.
Although the United States is an international mega-power, it as much to learn, Dr. Hemenway says, noting that “every other country has shown us the way to vastly reduce our problems.” That means if other countries can get control of gun reasonability — as New Zealand did in a hurry following its first mass shooting — we can, too.
Repeated surveys of Americans say they favor universal background checks. As recent history has shown, whether or not that will come to fruition still remains unanswered.
Prevent Rather Than Repair
The idea of “community” as it relates to “public” means motivating responsible gun owners, says Dr. Hemenway, citing his colleague Cathy Barber, M.P.A., at T.H. Chan’s Means Matter campaign. She collaborates on a number of pertinent issues with gun owners, advocates and trainers, as well as gun shop owners.
Dr. Hemenway’s must-do list includes licensing of gun owners and all that entails, including strong background checks, and only allowing firearm sales to a licensed owner. He also recommends a federal agency to oversee the massive gun issue — a heretofore novel and yet seemingly sound idea.
The medical community has taken its stand on the public health effects of gun violence after frequently describing for the rest of us in riveting detail what it’s like to treat victims of shootings. Formally, members have established the nonprofit American Foundation for Firearm Injury Reduction in medicine (AFFIRM), with more than 40,000 healthcare colleagues.
The group seeks to inform medical protocols for their peers on the frontlines of gun violence, and to engage other first responders and stakeholders, as well as to educate and inform the public. They say they’d rather prevent than repair, and they worry about a culture of indifference and acceptance — of normalization that leads to divisiveness in this nation.
Meeting of the Minds Needed
It’s tough to solve a problem if stakeholders can’t come together to share ideas and solutions, the kind of proactive collaboration that provided results and conclusions around seat belts and smoking.
So why doesn’t the federal government jump headlong into gun violence research, specifically the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH)? The Dickey Amendment came to fruition in the early 1990s when gun violence did become a public health issue.
The National Rifle Association (NRA) said then that the CDC was biased against guns, and attracted Congressional support that basically eliminated any funding “to advocate or promote gun control”: That meant no studies related to firearms, and in 2011, the amendment reached to the NIH. After the Sandy Hook school shooting, President Obama told the CDC that the Dickey Amendment shouldn’t completely ignore funding for gun violence research, but Congress stopped it nonetheless. Currently, the amendment isn’t really in effect but there’s still no funding.
To that end, early this year, Rep. Carolyn Maloney (D-NY) introduced H.R. 674 and Sen. Edward Markey (D-MA) introduced S.184, the Gun Violence Prevention Research Act of 2019, which was referred to the Subcommittee on Health, where it’s been languishing. It would provide CDC funding to study gun violence for the next five fiscal years.
Random Attacks Are Few
If the United States is unable to tackle more research into gun violence, that hasn’t stopped smaller, independent studies, like one from the state of Utah. It published a report in 2018 with the T.H. Chan School, looking at suicide and firearm injury. It was supported by both parties, and by gun rights champions.
The results showed that 87 percent of those who died by suicide could have passed a background check and that Utahns with mental health or drinking issues weren’t properly storing or locking up guns. The most surprising fact: Those random attacks that people are warned about as reasons to carry guns occurred only three or four times a year.
So with all we know and all that’s yet to be known if more scientific research is conducted, the following have been suggested as remedies to the gun violence epidemic. The solutions run the gamut from more basic to creative:
Also mentioned as possible solutions:
Scientific American sees it this way, opining that we just don’t know enough about gun violence perpetrators and we should.
Did they get firearms legally, or how did they get them?
Are our current laws being used to disarm dangerous people?
What do we do about the proliferation of underground gun markets?
How can we better evaluate violence prevention policies and programs, as in “Do they work?”
As the editorial board notes, research doesn’t infringe on Second Amendment rights, but it does support those other, unalienable rights we are all due, thanks to the Declaration of Independence. Don’t forget “Life, Liberty and the pursuit of Happiness.”
We have an intuitive sense that things like what we eat, how much we exercise, the quality of our water and air, and getting appropriate health care when sick all help us stay healthy, but how much do each of these factors matter?
Studies have also shown that our incomes, education, even racial identity are associated with health — so-called “social determinants of health.”
How much do social determinants matter? How much does the health system improve our health?
In the 1970s the Centers for Disease Control and Prevention tried to answer these questions but had little rigorous science to guide it. Though we know a great deal more today, they still have not been fully answered. This is no mere curiosity — knowing what makes us healthy will help us direct investments into the right programs.
Over the years, many frameworks have been developed to illuminate what affects health. The relationships are so complex that no single framework captures everything. To get us started on this research project — and our broader conversation about what drives health — we created a model that allows us to explore some of the dimensions of these drivers, and their relationships to each other.
We developed our framework by reviewing research on factors that influence health and surveying similar projects and tools from prominent organizations . It is not meant to be complete, but a starting point that allows us to think about what drives health and how.
Indirect vs. Direct Factors
Many things affect health, some directly and others indirectly. Government/policy, income/wealth, education, and racial identity don’t necessarily affect health in an immediate way. They are indirect factors that tend to affect health through complex pathways. Those pathways usually involve other factors that more immediately affect health. These are the direct factors such as occupation, health care access, and health behaviors.
Why these Outcomes?
There are many possible health outcomes. The framework includes four examples—age-adjusted mortality, life expectancy, quality of life/well-being, and functional status. These outcomes are commonly studied, prevalent in the literature, and reflect the kinds of things people care most about.
A wide range of government policies can affect health. For example, in 2007, Australia became the first country to introduce a government-funded human papillomavirus (HPV) vaccination program. For years later, significantly lower levels of HPV were present in the population. As another example, studies show that Medicaid expansion in the US facilitates access to care and improves self-reported health outcomes. Policies outside the health system can affect health too. Those pertaining to deportation of undocumented immigrants and same-sex marriage have been linked to health outcomes, for example.
Income and wealth are associated with health, but through complex pathways. While income and wealth facilitate access to health care, food, and housing, it’s also true that good health facilitates labor force participation, potentially leading to higher income. Several studies suggest that income and resources have profound effects in early life and development, but a much smaller effect on adults.
Racial Identity is closely associated with health outcomes in the US. For example, African-American adults experience much higher levels of mortality than white adults, from all causes. Racial Identity also plays a role in the accumulated stress from discrimination and in the quality of health care received.
Evidence suggests that gender identity plays a role in health and health care. For example, one study found that women with angina pectoris and low socioeconomic status were referred to cardiologists less frequently than men.
Genetics play a role in the development of certain disease. For example, while cancer is not caused by genetics, most cancers have some genetic determinants. The BRCA1 and BRCA2 genes play a role in tumor suppression, and, when mutated, increase the risk of female breast, ovarian, and other cancers.
Environmental factors — natural and built — have profound effects on our health. Of course, factors like air quality affect our health, evidenced by a study that demonstrated an association between higher levels of air pollutants O3 and PM2.5 and pediatric pneumonia. Environmental conditions even before birth (present during fetal development) can affect health and well-being into adulthood.
Medical care is designed to facilitate good health, so both the quality of medical care and access to it influence our health outcomes. One study found that the medically uninsured receive 20% less care after auto accidents and have significantly higher mortality rates than people who are insured.
Health behaviors encompass a wide range of human behaviors that affect health including: physical activity; diet; sleep; and tobacco, alcohol, and other substance use. Just as one example, reducing exposure to tobacco has been identified as the single biggest way to prevent morbidity, disability, and early death.
Social relationships can affect mental and physical health as well as behaviors and mortality risk. The people we are surrounded by (at an early age, parents, and later in life, peers and romantic partners) strongly influence health through mechanisms of stress, social support, and pressure to engage in or avoid risky behaviors.
Occupation is linked to health outcomes, and may both cause health due to the conditions of the job, and be caused by health due to the limitations particular to certain conditions.
Historical vs. Current, Marginal Effects
When attempting to quantify the impact of direct health-related factors, it is important to make a distinction between how much of our current health is related to these factors versus how much of our current health can be improved by interventions that target particular factors. Grasping this distinction is critical so that we know where our dollars are best spent to maximize health improvement. In other words, how much have each of these factors affected our health in the past through today versus how much could they affect health in the future if policy was immediately changed? For example, a disease like smallpox has a huge direct effect on health outcomes, but it has essentially been eradicated, so an additional investment in eradicating smallpox has virtually no marginal gains, even though the disease is closely linked to health.
It is also relevant to consider the timespan on which we see certain effects taking place, especially when considering policy intervention. For example, with an environmental change such as improving the air quality, it would take a significant amount of time for all measurable changes in health outcomes to manifest; other interventions, such as dramatically increasing flu vaccination rates, could have significant health outcomes that would be observable on a much shorter timescale.
Correlations vs. Causation
Considering the available literature on social determinants of health and the links between these factors and measurable health outcomes, it is critical to clarify whether what we are observing or seeking is a correlation or causation. Correlations can guide hypothesis generation, but only causation is actionable in terms of policy.
Finally, it is worth considering how a framework like this relates to policy intervention. The specific interventions that might be effective within a category (e.g., health behaviors) could change over time. For example, promotion of wearing motor vehicle seat belts was an important area for policy interventions in the 1970s and 1980s, but is less so now because doing so has become commonplace. Though health behaviors remain relevant to health today, the class of interventions that would have the largest impact are different.