The public health emergency of climate change: how/are Canadian post-secondary public health sciences programs responding?

ObjectiveThe Intergovernmental Panel on Climate Change recently issued a statement that the fate of human society and human health is at serious risk of catastrophic impacts unless we take bold action to keep global warming under 1.5 °C. In 2015, the Canadian Public Health Association noted emerging efforts to embrace intersectoral approaches to global change in public health research and practice. In this study, we question the extent to which Canadian Graduate Public Health Sciences Programs have kept pace with these efforts to see climate change surface as a new frontier for training the next generation of researchers and practitioners.MethodsSemi-structured interviews (19) were conducted with Department Heads (or equivalents) of graduate-level Public Health Sciences Programs at 15 Canadian universities concerning the place of climate change in their respective curricula. Interviews were designed to elicit participants’ institutional perspectives on the importance of climate change in the Public Health Sciences and identify perceived challenges and opportunities.ResultsDespite wide recognition among participants that climate change is a public health “crisis”, very few reported having substantive curricular engagement on the topic. Key challenges identified were lack of resources, organizational issues, and political barriers. Key opportunities to adapt curricula to address this new frontier in Public Health were faculty interest and expertise, cross-disciplinary collaboration, and pressure from the institution.ConclusionOur findings provide evidence for post-secondary Public Health Sciences Programs to understand the need to address their own sluggishness when what is needed are bold, even radical, shifts to existing curricula.     

Developing and implementing a targeted health-focused climate communications campaign in Ontario—#MakeItBetter

SettingPublic health practitioners are called to effectively communicate with the public on climate change. The climate crisis requires swift action that starts with public awareness of climate-related health impacts and leads to public support for individual, community and systemic actions to mitigate and adapt to climate change.InterventionThis paper discusses learnings about public opinion research and communication strategies and how a health-focused climate communication campaign—#MakeItBetter—could help to increase awareness and engage new audiences, including public health partners, in conversations about climate change in order to reduce climate-related health impacts for current and future generations. The #MakeItBetter campaign was grounded in evidence-informed messaging, being sensitive to health inequities. Emerging research and pre-campaign testing suggest that framing climate change as a health issue is a promising practice.OutcomesThe #MakeItBetter campaign appeals to parents/caregivers to learn more about climate-related health impacts, take protective action for children and support multi-level climate action. The campaign launch secured 89 news stories, including multicultural media coverage. Longer-term evaluation is required to determine the campaign’s effectiveness in building public support for climate action.ImplicationsAn innovative approach to climate communication that draws on the intersections between behavioural and climate sciences and engages in multi-sectoral collaboration can spur both climate action and health protection, aiding public health practitioners and partners in effectively communicating the urgency for climate action. More work is needed to support communication on climate change as an inequity multiplier and promote climate action and community resilience for health equity co-benefits.     

Expected Ethical Competencies of Public Health Professionals and Graduate Curricula in Accredited Schools of Public Health in North America

Objectives. We assessed expected ethics competencies of public health professionals in codes and competencies, reviewed ethics instruction at schools of public health, and recommended ways to bridge the gap between them.Methods. We reviewed the code of ethics and 3 sets of competencies, separating ethics-related competencies into 3 domains: professional, research, and public health. We reviewed ethics course requirements in 2010–2011 on the Internet sites of 46 graduate schools of public health and categorized courses as required, not required, or undetermined.Results. Half of schools (n = 23) required an ethics course for graduation (master’s or doctoral level), 21 did not, and 2 had no information. Sixteen of 23 required courses were 3-credit courses. Course content varied from 1 ethics topic to many topics addressing multiple ethics domains.Conclusions. Consistent ethics education and competency evaluation can be accomplished through a combination of a required course addressing the 3 domains, integration of ethics topics in other courses, and “booster” trainings. Enhancing ethics competence of public health professionals is important to address the ethical questions that arise in public health research, surveillance, practice, and policy.Public health as a profession has a long history of expecting ethical behavior by its providers, scientists, and decision-makers. With early influences from medicine and nursing, laboratory science, and epidemiology, to more contemporary disciplines (e.g., behavioral science and engineering), public health consists of diverse professions,1 each of which contributes unique training, expectations of professional behavior, and discipline-specific codes of ethics. The common link that brings these disparate professionals together is the need for collective effort to improve health through a population focus.2Public health’s population focus presents unique ethics considerations that differ from those reflected in biomedicine and clinical care. Interactions between health care providers and patients emphasize the clinician’s obligation to the patient and the patient’s autonomy. Emphasis on the individual presents a challenge to public health professionals whose “patient” is the community or population. Since the early 2000s, at least a dozen public health ethics frameworks offered by scholars and practitioners have discussed the tensions that occur between autonomy and community responsibility.3 Public health professionals, many of whom are trained in medicine and allied health, understand that ethical challenges arise in the population setting, in public health practice, and public health research. The purpose of this assessment was to assess the expected ethical competencies of public health professionals as reflected in published codes and competencies, review current ethics instruction at schools of public health (SPH), and recommend ways to bridge the gap between what is expected and what is currently taught in graduate level courses.     

Data-Driven Dietary Patterns,Nutrient Intake and Body Weight Status in a Cross-Section of Singaporean Children Aged 6–12 Years

Pattern analysis of children’s diet may provide insights into chronic disease risk in adolescence and adulthood. This study aimed to assess dietary patterns of young Singaporean children using cluster analysis. An existing dataset included 15,820 items consumed by 561 participants (aged 6–12 years) over 2 days of dietary recall. Thirty-seven food groups were defined and expressed as a percentage contribution of total energy. Dietary patterns were identified using k-means cluster analysis. Three clusters were identified, “Western”, “Convenience” and “Local/hawker”, none of which were defined by more prudent dietary choices. The “Convenience” cluster group had the lowest total energy intake (mean 85.8 ± SD 25.3% of Average Requirement for Energy) compared to the other groups (95.4 ± 25.9% for “Western” and 93.4 ± 25.3% for “Local/hawker”, p < 0.001) but also had the lowest calcium intake (66.3 ± 34.7% of Recommended Dietary Allowance), similar to intake in the “Local/hawker” group (69.5 ± 38.9%) but less than the “Western” group (82.8 ± 36.1%, p < 0.001). These findings highlight the need for longitudinal analysis of dietary habit in younger Singaporeans in order to better define public health messaging targeted at reducing risk of major noncommunicable disease.     

The Common Ground Preparedness Framework: A Comprehensive Description of Public Health Emergency Preparedness

Currently, public health emergency preparedness (PHEP) is not well defined. Discussions about public health preparedness often make little progress, for lack of a shared understanding of the topic. We present a concise yet comprehensive framework describing PHEP activities. The framework, which was refined for 3 years by state and local health departments, uses terms easily recognized by the public health workforce within an information flow consistent with the National Incident Management System. To assess the framework''s completeness, strengths, and weaknesses, we compare it to 4 other frameworks: the RAND Corporation''s PREPARE Pandemic Influenza Quality Improvement Toolkit, the National Response Framework''s Public Health and Medical Services Functional Areas, the National Health Security Strategy Capabilities List, and the Centers for Disease Control and Prevention''s PHEP Capabilities.“All models are wrong, some models are useful.”—George Box1Public health emergency preparedness (PHEP) has been defined as “the capability of the public health and health care systems, communities, and individuals, to prevent, protect against, quickly respond to, and recover from health emergencies, particularly those whose scale, timing, or unpredictability threatens to overwhelm routine capabilities.”2^(p24) However, compared with more traditional public health activities such as food safety inspections, outbreak investigations, community health assessments, immunization clinics, and environmental monitoring, PHEP activities are not clearly defined.2–4We present a framework describing what public health agencies do to prepare for, respond to, and recover from public health emergencies. The framework was developed through a collaboration of state and local health departments, brought together by the Public Health Informatics Institute with funding from the Robert Wood Johnson Foundation to define business processes related to PHEP.The Common Ground Preparedness Framework (CGPF) adds to other PHEP frameworks by more explicitly capturing how public health agencies prepare for and respond to public health emergencies. Combining comprehensiveness with specificity, it is especially useful in describing PHEP to both public health agencies and their partners in emergency response. It also provides a framework for incident action plans and after-action assessments, resource distribution, information systems, and training.     

Appropriateness of COVID-19 public health guidelines for an Alberta First Nations community

ObjectivesThe First Nations people experience significant challenges that may influence the ability to follow COVID-19 public health directives on-reserve. This study aimed to describe experiences, perceptions and circumstances of an Alberta First Nations community, related to COVID-19 public health advice. We hypothesized that many challenges ensued when following and implementing advice from public health experts.MethodsWith First Nations leadership and staff, an online cross-sectional survey was deployed between April 24 and June 25, 2020. It assessed the appropriateness of public health advice to curb COVID-19 within this large First Nations community. Both quantitative and qualitative data were captured and described.ResultsA total of 106 adults living on-reserve responded; over 80% were female. Difficulty accessing food was significant by employment status (p = 0.0004). Those people with lower income found accessing food (p = 0.0190) and getting essential medical care (p = 0.0060), clothing (p = 0.0280) and transportation (p = 0.0027) more difficult. Some respondents described lost income associated with COVID-19 experiences, as well as difficulties accessing essential supplies. Respondents found “proper handwashing” most easy (98%) and “keeping a distance of 2 m from others” most difficult (23%). Many respondents found following public health advice within their personal domain easy and put “family safety” first but experienced some difficulties when navigating social aspects and obligations, particularly when unable to control the actions of others. People stated wanting clear information, but were sometimes critical of the COVID-19 response.ConclusionFirst Nations people face many additional challenges within the COVID-19 response, driven in part by ongoing issues related to significant societal, economic, and systemic factors.Supplementary InformationThe online version contains supplementary material available at 10.17269/s41997-021-00579-4.     

Weight bias and support of public health policies

ObjectivesPublic health policies have been proposed to help address prevalent Canadian obesity rates. Along with the increase in obesity prevalence, explicit weight bias is also rampant in Western society. This paper aimed to assess the association between explicit weight bias attitudes and Canadian public support of these policy recommendations.MethodsCanadian adults (N = 903; 51% female; BMI = 27.3 ± 7.0 kg/m²) completed an online survey measuring explicit weight bias, using the three subscales of the Anti-Fat Attitudes Questionnaire: Willpower (belief in weight controllability), Fear of fat (fear of gaining weight), and Dislike (antipathy towards people with obesity). Whether these subscales were associated with policy support was assessed with logistic regression. Analyses were adjusted for age, race, gender, and income.ResultsPublic support of policy recommendations ranged from 53% to 90%. Explicit weight bias was primarily expressed through a fear of weight gain and the belief that weight gain was within the individual’s control based on willpower. Although the Dislike subscale was associated with lower support for several policies that enable or guide individual choice in behaviour change, the Willpower and Fear of fat subscales were associated with greater support for similar policies.ConclusionThis study contributes to evidence-informed public health action by describing public support of public health policies and demonstrating an association between explicit weight bias and public support. A higher total explicit weight bias score increased the odds of supporting primarily less intrusive policies. However, dislike of individuals with obesity was associated with decreased odds of supporting many policies.     

Local Legal Infrastructure and Population Health

Objectives. We explored the association between the legal infrastructure of local public health, as expressed in the exercise of local fiscal and legislative authority, and local population health outcomes.Methods. Our unit of analysis was public health jurisdictions with at least 100 000 residents. The dependent variable was jurisdiction premature mortality rates obtained from the Mobilize Action Toward Community Health (MATCH) database. Our primary independent variables represented local public health’s legal infrastructure: home rule status, board of health power, county government structure, and type of public health delivery system. Several control variables were included. We used a regression model to test the relationship between the varieties of local public health legal infrastructure identified and population health status.Results. The analyses suggested that public health legal infrastructure, particularly reformed county government, had a significant effect on population health status as a mediator of social determinants of health.Conclusions. Because states shape the legal infrastructure of local public health through power-sharing arrangements, our findings suggested recommendations for state legislation that positions local public health systems for optimal impact. Much more research is needed to elucidate the complex relationships among law, social capital, and population health status.To understand law’s contribution to community health, we must identify the association between legal structures and population health indicators. This study addresses the broad legal foundations for public health improvement known as infrastructural public health law, those “laws that create and empower public health agencies and jurisdictions.”1^(p17)The observation that public health systems vary in legal infrastructure and its expression is not new. In 1981, DeFriese et al. classified local public health systems as centralized, decentralized, or shared-control and observed that “statutes could not be relied upon to provide accurate indications of actual health department organization.”2^(p1114) This insight foreshadowed a fundamental tenet of public health law research: the text of a statute or regulation alone cannot account for the full effect of law on population health.3–5 Authority granted by state law to local agencies is a necessary but not sufficient condition of local decisional autonomy.6The Institute of Medicine’s 2003 report The Future of the Public’s Health in the 21st Century pointed to the need for research in this area by characterizing the legal foundation of public health as “replete with obsolete and inconsistent laws and regulations,” a “state of affairs [that] sometimes complicates rather than facilitates governmental contributions to the public health system.”7(p26) Likewise, Mays et al. noted,

Empirical studies are needed to describe the range of legal structures currently used for distributing governmental public health powers among state and local agencies and to compare the effectiveness of these structures.^8(p263)

Examinations of the nature, extent, and mechanisms of local public health systems’ impact on population health were infrequent until the emergence of public health systems and services research as a focused area of inquiry.9,10 Public health systems research has now identified typological models that can support comparative studies to identify variation in performance.11,12 A stronger evidence base for change can inform health law reform initiatives and improve their likelihood of success.     

PROPER RELATION OF FEDERAL AND STATE GOVERNMENTS IN PUBLIC HEALTH WORK

How far should the Federal Government go in dictating state health policy? Dr. McLaughlin says that it should coördinate state departments just as these coördinate the departments of cities. “The United States Public Health Service,” he says, “has a detailed, comprehensive nation-wide program for every public health problem, but these programs can not be put into effect without adequate funds.”     

Community Medicine in India — Which Way Forward?

Today, the Community Medicine professionals in India feel both “confused” and “threatened” by the mushrooming of schools of public health and departments of family medicine. The phenomenon of identity crisis and low-self esteem is not a recent one, nor is it restricted to India. The disciplines of community medicine and public health have evolved differently and despite some overlaps have differences especially in the need for clinical training. The core of the issue is that while the community medicine fraternity is keen to retain its clinical tag, what differentiates it from clinicians is the use of public health approach. I believe the strength of community medicine is that it bridges the gap between traditional fields of public health and clinical medicine and brings community perspective into health. The perceived threat from non-medical persons led public health is largely a result of us undervaluing our strength and our inability to foster partnership on equal footing with non-clinicians. While departments of community medicine have a fully functional rural or urban field practice area used for training at primary level care, these can serve as an excellent platform for training in secondary level care required for family medicine. National needs dictate that all three disciplines are required for improvement of population health, whether these are housed together or separately can be left to individual institutions to decide as long as they enable collaborations between them. We need to strengthen community medicine and market it appropriately to ministries of health.     

Textual analysis of sugar industry influence on the World Health Organization’s 2015 sugars intake guideline

ObjectiveTo determine whether sugar industry-related organizations influenced textual changes between the draft and final versions of the World Health Organization’s (WHO’s) 2015 guideline Sugars intake for adults and children.MethodsStakeholder consultation submissions on the draft guideline from seven sugar industry-related and 10 public health organizations were assessed using the Wordscores program. Document scores were rescaled using the Martin–Vanberg transformation to improve comparability. Draft and final guidelines were compared to identify changes influenced by the sugar industry and public health organizations.FindingsThere was a small shift in transformed Wordscores score between the draft and final guidelines, from 0.25 to 0.24, towards the industry position. The change was linked to increased use of the word “low” to describe the quality of the evidence, consistent with industry arguments. There was also a shift from use of the word “consumption” to “intake”, irrespective of policy position. Scores for World Sugar Research Organisation and Sugar Nutrition UK submissions ( 0.11 and 0.18, respectively) represented strong pro-industry positions and scores for European Public Health Alliance and Wemos submissions (1.00 and 0.88, respectively) represented the strongest public health positions. Industry tactics included challenging the quality of the evidence, distinguishing between different types of sugar and advocating harm reduction.ConclusionThere was little change between draft and final versions of the WHO sugars intake guideline 2015, following industry consultation. The main change was linked to emphasizing the low quality of the evidence on sugar’s adverse effects. Guideline development appeared relatively resistant to industry influence at the stakeholder consultation stage.     

Lifeworld-led care: Is it relevant for well-being and the fifth wave of public health action?

A recent paper has made the case for a “fifth wave” of public health action. The paper articulated the first four waves as focusing on civil engineering, the germ theory of disease, welfare reforms and lifestyle issues. This article will focus on well-being and will expand on the authors’ articulation of a current need to “discover a new image of what it is to be human” to begin to address the challenges of promoting well-being. This article will consider an alternative way of viewing human beings within a “caring” context and how this alternative view may aid this potential fifth wave of public health action. This alternative view has emerged from the work of Husserl who suggested that any human view of the world without subjectivity has excluded its basic foundation. The phenomenological understanding of “lifeworld” is articulated through five elements, temporality, spaciality, intersubjectivity, embodiment and mood that are all discussed here in detail. A world of colours, sparkling stars, memories, happiness, joy, anger and sadness. It is this “lifeworld’ that when health care or as argued in this article as public health becomes overly focused on decontextualized goals, and measuring quality superficially can be neglected.     

The correlation between mental health and multiple chemical sensitivity: a survey study in Japanese workers

Objective

This study was designed to determine the correlation between mental health and multiple chemical sensitivity (MCS).

Method

The present study was conducted at two companies in 2011; both in Kyushu, Japan. The “subjective symptoms” subscale of the “Self-diagnosis Checklist for Assessment of Workers’ Accumulated Fatigue” was used as a mental health subscale. To determine if multiple chemical exposure has an impact on mental health, we composed an original path model using structural equation analysis.

Result

Our final path model can be regarded as good: CMIN/DF = 1.832, CFI = 0.996, and RMSEA = 0.038, AIC = 71.158. As expected, chemical sensitivity and other chemical sensitivity scores predicted the health effects of multiple chemical exposure (β = 0.19, 0.64). Mental health was predicted by symptom severity and life impact (β = 0.56 and 0.12), which were both affected by multiple chemical exposure (β = 0.38 and 0.89, respectively).

Conclusion

As far as we are aware, this is the first study using path analysis to explore whether MCS can indicate mental health in worker populations worldwide, and we found a significant causal relationship between them. This could indicate that more focus should be placed on the impact of MCS on mental health in future investigations.     

La promozione della salute nei luoghi di lavoro

«Workplace health promotion». Workplace Health Promotion (WHP-Workplace Health Promotion) is aimed at improving the workers’ well-being and health, so as to guarantee conditions of greater psycho-physical well-being and work capacity for a future elderly population. Cost-benefit analysis studies indicate that the return of profits compared to the invested capital (Return of investment - ROI) can be very good. To conduct WHP’s activities successfully, the continuous and convinced commitment of all corporate subjects is required. WHP interventions must not represent alternative paths to those of Prevention and Safety, nor represent “discount” tools with respect to regulatory obligations. It is essential that there be clarity in the roles played by public institutions operators (USL / ASL / ATS) who, in various capacities and in various sectors, are involved. At the moment, in terms of WHP, the regions have responded differently and in any case the difficulties in applying the WHP to SMEs have become evident. Whatever the approach, WHP’s actions must take into account the end-point, ie the health gain of the workers involved due to the specific effect of the action promoted and for this reason the programs must provide an adequate follow-up, which becomes an element indispensable for any proposal. Health promotion in the “work” context has, with respect to more traditional contexts (such as school or community), undoubtedly peculiarities, which require a specific training of “health promoters” engaged in this field.Key words: Health promotion, workplaces, assessment     

FUTURE CO?PERATION BETWEEN THE AMERICAN RED CROSS AND PUBLIC HEALTH AGENCIES

Since the cessation of hostilities in Europe health officers have been asking “What is the Red Cross going to do in Public Health?” Dr. Farrand here assures the public health profession that the Red Cross proposes to be a coöperative agency and not unless circumstances seem to demand it, an operative one.     

Toward Better Estimates of the Cost of Climate Change Mitigation: Guidelines for Studying Potential Health Benefits

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Worldwide, efforts to mitigate climate change through reduction of greenhouse gas emissions are falling short of what is needed to meet ambitious international goals such as the Paris Agreement.1 Research estimating the health effects of mitigation (HEM) indicates that climate change mitigation activities could have substantial health co-benefits that partially or completely offset the economic costs of mitigation. Yet few HEM findings have been incorporated into cost estimates of mitigation activities, making the activities appear unacceptably expensive to policymakers.2 The authors of a recent commentary in Environmental Health Perspectives present guidelines for conducting and reporting HEM studies so that the results are comparable and responsive to stakeholder priorities and that health benefits are thus more often considered in cost estimates.3Open in a separate windowClimate change mitigation activities often produce health co-benefits in addition to simply reducing greenhouse gas emissions. For example, installing wind power facilities to replace coal-fired power plants means fewer hazardous air pollutants in regional and local air. That could result in fewer hospitalizations for respiratory diseases. Image: © iStockphoto/Baxternator.HEM research has often operated in a silo, not effectively engaging stakeholders in the research process. That could be one reason for the low uptake of their recommendations by policy makers, according to lead commentary author Jeremy Hess, a professor in the University of Washington’s Department of Environmental and Occupational Health Sciences. The University of Washington, the World Health Organization, and the Wellcome Trust’s Our Planet, Our Health funding foundation jointly convened a workshop in London to develop consistent guidelines for planning and reporting HEM research. Among these guidelines were recommendations for how to better engage stakeholders in the research process—ultimately leading to increased uptake when developing mitigation policies.“Ultimately, HEM research aims to inform policy decisions,” says Hess. “Without knowing the priorities of policy makers and how they might use the estimates, such research is at risk of being ignored. Dialogues between policy makers and scientists take time, and such processes are often not supported as part of research activities.”Led by Hess and Kristie Ebi—also a professor of Environmental and Occupational Health Sciences at the University of Washington—the team conducted a modified Delphi process to reach preliminary consensus on issues related to engaging stakeholders before scoping projects, modeling approaches to use, choices about model parameters, and communicating results. The outcome was then discussed in depth at the expert workshop.At the end of the process, the authors developed a list of specific recommendations to optimize stakeholder engagement and study design and reporting. They encouraged the creation of trans- and interdisciplinary stakeholder teams to more thoughtfully develop research questions and anticipate unforeseen consequences. They also recommended ways to ensure future HEM studies yield high-quality results, including best practices for describing the study population and health metrics used, reporting counterfactual scenarios, accounting for different levels of policy uptake, and sharing data.“As the paper notes, a wide range of methods have been used to evaluate ancillary health benefits and costs of technologies and policies to reduce carbon emissions,” says Tracey Holloway, a professor of environmental studies at the University of Wisconsin–Madison who was not involved with the paper. “With so many different study design approaches, it can be difficult to compare study results in an ‘apples to apples’ manner. This study lays a roadmap for future work to enhance the rigor, comparability, and relevance to decision makers.”“I would have loved to see a few specific examples—case studies to show the recommendations in practice,” Holloway adds. “Sharing a few concrete examples would clarify some of the points in the paper, especially to readers who may not have thought about the nuts and bolts of studies like this.”Despite the emphasis on engaging stakeholders and developing more standardized approaches, that result is not assured, says Michael Brauer, a professor of occupational and environmental health at the University of British Columbia who also was not an author of the commentary. “The goal of standardization as a means to hopefully increase uptake of these kinds of analyses for policy development and implementation is certainly worthwhile,” Brauer says. “But even if this guidance is followed, it certainly doesn’t guarantee that there will be more use of [HEM] analyses in policy prioritization.”That is nevertheless the ultimate aim of the guidance. “At the end of the day, we hope these guidelines will lead to more widespread, rapid implementation of climate change mitigation, which will be good for health,” says Hess. “It will help reduce the risks of dangerous climate change in the long run and will produce a raft of important health benefits starting almost immediately.”     

Aftershocks: Home Loss and Long-Term Health after the 2011 Great East Japan Earthquake

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From hurricanes to earthquakes, natural disasters affect survivors in innumerable ways, including adverse effects on mental¹ and physical² health. Only a few studies have been able to assess a consistent set of health indicators both before and after a disaster due to the unpredictability of such events. However, in a study recently published in Environmental Health Perspectives,³ a team of researchers was able to use preexisting data from the Japan Gerontological Evaluation Study to assess a wide array of health and well-being outcomes before and up to 9 years after the 2011 Great East Japan Earthquake.The authors used data from a cohort of older individuals who came from the city of Iwanuma. The tsunami that followed the earthquake killed more than 180 people in Iwanuma, inundated nearly half the city, and destroyed 5,542 houses. Most of the 2,167 individuals in the current study sustained some degree of damage to their homes during the 2011 disaster; 4% suffered a complete home loss.Open in a separate windowThe Great East Japan Earthquake and related tsunami completely destroyed 122,000 dwellings in all and damaged another 1 million, according to estimates from 2021.⁵ Image: © Gallo Images/Contributor via Getty Images.The study examined the longitudinal associations between complete home loss specifically and 34 health indicators categorized as physical health, mental health (e.g., symptoms of depression or posttraumatic stress), health behaviors/sleep (e.g., dozing off during the day), social well-being (participation in society), cognitive social capital (perceptions about social relations in the community), subjective well-being (happiness and life satisfaction), and prosocial or altruistic behaviors (e.g., sharing). This “outcome-wide” framework—namely, assessing the relationship between a single exposure and multiple outcomes—is a relatively new approach.⁴“Epidemiologic research on disaster survivors has focused on mental health problems as an outcome,” says lead author Koichiro Shiba, a postdoctoral research fellow at the Harvard T.H. Chan School of Public Health. “We know little about how a disaster influences key aspects of human well-being that cannot be captured by looking at mental health alone. This knowledge gap motivated us to employ the outcome-wide framework to examine the relationship between the disaster experience and well-being.”After 9 years, complete home loss was associated with increased symptoms of posttraumatic stress, depression, and hopelessness. People who lost their homes were also more likely to experience daytime sleepiness along with lower levels of trust in the community, community attachment, perceptions of mutual help in the community, and prosociality. The researchers saw more modest associations between complete home loss and having more chronic conditions, higher body mass index, and decreased happiness. Home loss was not associated with the remaining indicators.“The most surprising result to me was the strong association between home loss and decreased social capital; it is notable that the association persisted even nine years after the disaster,” Shiba says. “By that time, buildings in the flooded area had been rebuilt and people had already moved out of the temporary shelters and lived in permanent housing. It is difficult and takes time to reconstruct social capital once it is destroyed, highlighting the importance of efforts to preserve preexisting social capital.”“This is an excellent piece of scholarship. The longevity of the disruptive effect is astonishing: 9 years post-event, participants are still experiencing distress related to the earthquake event,” says Katie E. Cherry, the Emogene Pliner Distinguished Professor of Aging Studies at Louisiana State University and author The Other Side of Suffering, which covers her research on survivor recovery after Hurricanes Katrina and Rita. “Most important from a methodological point of view is the authors’ use of a prospective design,” she says, explaining that the availability of pre-event data allowed for a cleaner assessment of earthquake exposure effects.“It’s nice to see the authors’ inclusion of social capital and mental health consequences as outcome variables,” Cherry adds. Yet she found the notion of cognitive social capital to be conceptually ambiguous. The authors included in that term trust and mutual help in the community, as well as community attachment. “There is a large [body of] literature on social capital, which is a well-established social science construct,” Cherry says. “To my knowledge, there may be a dimension of social capital that is cognitive, but I am not aware of a ‘cognitive social capital.’”“Although we intuitively understand that losing a home during a natural hazard or disaster is incredibly harmful, this study has used extensive quantitative data from more than 2,000 survivors over a decade to show how broadly damaging it can be,” says Daniel Aldrich, a professor of political science and public policy at Northeastern University. “It is not just the loss of one’s physical property that changes one’s life. It is also the forced relocation that follows which pulls people away from their pre-disaster family, neighbors, and friends. In short, they lose their social networks, and these networks are powerful determinants of social and mental health.”     

Making It Count: How to Achieve Structural Change with Community-Based Participatory Research Projects

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Low-income communities of color are inequitably burdened with pollution and its related health effects.1 Environmental health researchers sometimes conduct community-based participatory research projects in which residents help design research questions, collect data, and interpret results.2 Such collaboration often improves the academic rigor of these studies3 and helps inform residents of health risks.4 But does it actually bring about systemic change to economic, social, and political structures? The authors of a review in Environmental Health Perspectives sought to answer that question.5Open in a separate windowThe authors of the new review discussed examples of community-based participatory research projects that successfully effected change. In one, members of the Crow Environmental Health Steering Committee at Little Big Horn College partnered with Montana State University to study contaminants in well water on the Apsaálooke (Crow) Reservation. Crow members of the team (including graduate student Emery Three Irons, shown sampling tap water) used culturally appropriate methods to collect samples and educate fellow Tribal members about the risks of drinking contaminated water. Ultimately, says investigator Margaret Eggers, the best intervention has been to provide free home water coolers that dispense safe drinking water from 5-gallon refillable jugs. Image: Courtesy John Doyle (Apsaálooke)/Little Big Horn College.“I was interviewing community members, and some of their stories just kind of got to me,” says Leona Davis, the lead author of the review. A graduate student in environmental education, Davis was helping Mónica Ramírez-Andreotta, an environmental health science professor and one of her advisors at the University of Arizona, evaluate learning and outcomes of a cocreated citizen science program with disadvantaged communities in Arizona. One of these was Hayden, Arizona, a majority Latino town that is home to a copper smelter and piles of mine tailings.6 Although Davis recognized the residents’ environmental science literacy, she was struck by the glaring injustice of their situation. “I just remember … reflecting that this is a bigger issue than a lack of understanding of science,” says Davis.Davis and Ramírez-Andreotta reviewed the literature to investigate which specific study design elements prompt structural change to benefit overburdened communities. They found that 26 of the 154 case studies they examined resulted in structural change, which they defined as “affecting macro- or meso-level determinants of health, such as zoning policy, economic policy, political power, built environment, public service provision, or environmental policy enforcement.”Within those successful case studies, they found policy change was rarely a clear win, Davis says. For instance, in one case study,7 residents were unable to prevent a new waste facility from being built in their neighborhood. Still, they were able to negotiate a reduction in how much waste the facility handled and the removal of a diesel fueling station from the project. They also obtained guarantees that fleet vehicles would run on alternative fuels.The investigators also found that successful projects shared certain characteristics. During initial planning, these projects examined the structures already in place. They were community-directed, and they adopted governance models where community members held formal leadership roles. Hiring community members to serve as project leaders whenever possible is critical, says Ramírez-Andreotta. She explains that by providing a salary and funding for expenses, financial support for grassroots leadership makes it easier for residents—who are often grappling with poverty, illness, and other stressors—to work toward the changes they want to see.In projects that managed to bring about structural change, investigators had also valued the local knowledge and the lived experience of the community residents. They carefully translated the resulting data into a form that was understandable and useful for community members and other stakeholders. They also set policy change as a goal from the outset. Another key characteristic was commitment to a long-term presence in the community, which the authors defined as longer than 4 years. One case study8 examined the Detroit Community–Academic Urban Research Center, which has existed for more than 25 years and engaged in partnerships to address asthma, air quality, heart health, and other environmental health issues.9Those long-term commitments help build trust, something that can be sorely lacking between community members and academics, says Yanna Lambrinidou, co-organizer of the Engineering Ethics and Community Rights Collaborative, a national initiative to institute community rights in participatory research. “I think [the review] holds a mirror up to academics, asking us to reflect on our trustworthiness—on whether our educational, research, and funding structures are adequately designed to support community-led, systemic solutions or if they may at times even stand in the way,” says Lambrinidou, who was not involved with the review. “Environmental justice communities have been voicing concerns for a long time about academics who show up to help,” she continues. “Yet to this day, academia provides no space for these communities to report problems and no mechanism for protecting them from harm.”Davis and Ramírez-Andreotta hope their work will inform a new generation of investigators while acknowledging the steep systemic barriers to structural change. They point to one case study that involved the Aamjiwnaang First Nation community in Canada. For years, the group has collected data and filed numerous complaints about the dozens of surrounding petrochemical and polymer industrial facilities.10 Yet “despite years of formal complaints supported by empirical evidence,” the authors wrote, “the Canadian Ministry of the Environment continues to approve permits for local polluting industries.”Looking at such cases, the two researchers say, raises a deeply troubling reality: “[Injustice] isn’t because [these communities] lack understanding or education or resources,” says Davis. “It’s the belief that … some people deserve to be the dumping grounds of others. And so even the most robust data set or the snazziest data communication campaign is not going to shake that. You need additional tools.” The authors conclude that project designs that include decision makers and policy goals, as well as increased hiring of faculty of color who can potentially serve as “cultural knowledge brokers,” may be just such tools.     

The Return of the Pholela Experiment: Medical History and Primary Health Care in Post-Apartheid South Africa

I examine why South Africa’s pioneering Pholela model of primary health care, dating from the 1940s, held such appeal for the country’s new policymakers after 1994, and why those policymakers have failed to make it the basis of an effective public health care system since then. In the 1940s, the innovative Pholela experiment had served as such a model, to be replicated gradually throughout the country until a new health care system in its image was finally in place. However, this vision was dashed by the hostility of the mainstream medical profession and, after 1948, even more so by the new apartheid government, causing the idea to wither and become no more than a vanishing memory. In the 1990s, the model resurfaced as part of the country’s transition to democracy, eliciting great enthusiasm among a new generation of health policymakers. I conclude by looking at the fate to date of this second coming of the Pholela experiment.In April 1990, just two months after the release of Nelson Mandela from an apartheid prison and the unbanning of the African National Congress (ANC), its chief representative in Mozambique told an upbeat international conference on health in southern Africa that the party’s aim was to establish “a national health service in South Africa, based on the principles of primary health care and geared towards a programme of health for all by the year 2000.”1During the next 4 years of South Africa’s transition to a democratic political order, this goal was elaborated on by both the ANC and progressive public health specialists who shared its vision. In giving their enthusiastic support to the idea, several of the latter pointed out that this would not be the first time that the country had sought to mold its health system around primary health care; 50 years earlier, an official attempt to create a national health system based on primary health care–style health centers had briefly flourished.Between 1945 and 1948, following the innovative model of Sidney and Emily Kark’s Pholela Health Centre in deep rural Natal, 44 such health centers had been set up around the country by the national Department of Public Health as the foundation of a wholly new national health system. In the words of the National Health Services Commission (the Gluckman Commission), whose grand vision this was, such a system would provide the basis for “an organized National Health Service in conformity with the modern conception of ‘Health’ which will ensure adequate medical, dental, nursing and hospital services for all sections of the people of the Union of South Africa.”2That this ambitious scheme to reshape the country’s health system around an entirely novel principle had been cut short by a combination of medical, racial, and state politics in the years after 1948 only boosted the sense of triumph and joy that the ANC’s commitment to primary health care received from progressive health workers in the 1990s. As 2 of them, Steve Tollman and Derek Yach, wrote in the American Journal of Public Health in 1993, “As South Africa undergoes rapid social, economic, and political change, the rich heritage of public health and primary health care is being rediscovered. . . . The work at Pholela is now recognized as a highly effective example of a rural health center applying (indeed initiating) principles that are today seen as key to primary health care.”3 It seemed that, after 45 years of neglect under apartheid, the time had at last come for their resurrection.Doctors who had worked at Pholela as students in the 1950s now waxed lyrical about the lessons it held for the new, democratic South Africa. “Good ideas and concepts . . . may be rediscovered or re-invented—and may even flourish—in the face of urgent need, political upheaval, or both,” wrote one in 1993. “In South Africa, as the accession of the ANC approaches, the work of the Karks and their successors is now recalled, and the relevance of community health centers is appreciated as a possible centrepiece of the new national health care system that must soon emerge.”4 Even more glowing was the tribute of the editor of the American Journal of Public Health, Mervyn Susser, an ex-South African who had spent several months at Pholela in about 1950. In his eyes, the Karks’ innovations at Pholela were even more significant beyond South Africa, for he believed that “[Sidney] Kark assembled the girders on which, at some remove, the famous declaration of Alma Ata rests.”5Not surprisingly, therefore, when the aged Sidney and Emily Kark visited South Africa in 1992, they were fêted by progressive-minded health workers. The ANC’s shadow minister of health, Nkosazana Dlamini-Zuma (who had herself grown up near Pholela, cherishing “the African health workers and medical students” there as role models6), held lengthy consultations with them; medical school professors jostled to tell them of their own fledgling community-oriented primary care units, and even that old foe of primary health care, the South African Nursing Council, sought a meeting to discuss the role of community health nurses in a community-oriented primary care–based dispensation.7 “Wherever we went,” mused Sidney Kark, “there was a major interest in translating the concept of primary health care into practice.”8 The editor of the South African Medical Journal exuberantly declared in 1994, “The Pholela Health Centre was one of two spectacular attempts at health care innovation that surfaced in the early 1940s, well ahead of their time. The other was the report of the Gluckman Commission. . . . Today’s policy-makers need look no further for a model on which to base a sensible and effective primary health care network.”9Nor did they. Given its noble pedigree and the urgent need to extend health care equitably to all in the new South Africa, primary health care naturally formed the foundation of the ANC government’s National Health Bill, which aimed to transform the country’s health sector comprehensively. Through its many drafts between 1998 and 2003, when it was finally passed, the bill’s primary health care core remained unchallenged. Primary health care is “the basic ‘plank’ of our [new] health system,” explained James Ngculu, the chair of Parliament’s Portfolio Committee on Health,10 and the minister of health insisted that the new health system would be “based on primary health care. . . . It is our responsibility, nationally and provincially, to always protect the principle of primary health care in our country.”11 “As did Moses,” rhapsodized Ngculu, the act would “take the health system of our country to the promised land of equity and equality, efficiency and quality, and accelerate the long road to a better life for all.”12