Public Health: Myths and Realities

PUBLIC HEALTH
MYTHS AND REALITIES:
International University
for Graduate Studies
July 2012

Daniel
Jordan,
www.iugrad.edu.kn PhD, ABPP
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© Daniel Jordan, PhD, ABPP, drdanj@roadrunner.com

WHAT IS

Section I
PUBLIC
HEALTH?
© Daniel Jordan, PhD, ABPP, drdanj@roadrunner.com 改善

TWO PARABLES

Starfish
Downstreamers

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A New Parable of
the Downstreamers

Daniel Jordan, PhD, ABPP, drdanj@roadrunner.com

Adapted and Revised From: Ardell, D. (1986). The Parable of the Downstreamers. High Level
Wellness: An Alternative to Doctors, Drugs & Disease. Ten Speed Press. Berkeley, CA.

People Were Drowning!

 Downstream villagers saw the first
drowning person in the river many
years ago, but they could offer little
help.
 No one knew how to swim, so they
organized swim training.
 Some even got certificates and
advanced degrees.

People Kept Drowning!

 But more drowning people kept
floating down the river.
 Sometimes it took hours to pull
dozens from the river, and then
only a few would survive.
 Some drowners even jumped back
into the water and were swept
away.

People Kept Drowning!

 The Downstreamers wrote a grant
to get specialized life saving
equipment.
 They raised private funds to build a
waterside rescue facility.
 Volunteers staffed it 24/7.
 They finally got funds for paid staff.

But Things Just Got Worse!

 The number of victims kept
increasing, so . . .
 They analyzed specific patterns of
how people were floating down the
river, looked for specific eddies and
currents, then modified those water
flow patterns to reduce local risks
and improve the ability to respond

Finally Things Improved!

 Outcomes research showed that
Downstreamers’ rescues increased
from 27.8% to 62.3% in 20 minutes
or less, 16.7% are saved in 7
minutes or less!
 Downstreamers were very proud!
 They wrote articles, attended
conferences, got awards

Downstreamers were Proud
of Services and Supports . . .
 New hospital at the edge of the river,
 A flotilla of rescue boats ready,
 Comprehensive plans for staffing
 Highly trained and dedicated swimmers
ready to risk their lives
 Mental health counselors deal with
trauma

Downstreamers are Proud
of Services and Supports . . .
 This has been good for the economy
 A lot of “good people” have good
paying jobs, they also feel productive
and useful, fulfilled
 Downstreamers hold an awards
banquet every year
 They get government honors and
grants, newspaper articles

. . . But Some
Downstreamers Disagree
 They believe that people need to take
care of themselves
 They’re upset with having to help
people “who won’t help themselves” by
learning to swim
 They say other needs go unmet, and
they are being taxed to death for people
who aren't Downstreamers anyway,
send them back where they came from
 No new taxes!!!!!!

Both Groups Overlook
Some Key Questions.

Someone finally asks . . .

What’s Going on
Upstream??!!
Who Keeps Throwing People
in the River??!!

Are systemic causes
getting people in trouble?

And then in the most
Radical Act of All . . .

. . . a couple of
Downstreamers Shift
their focus:
They ask why drowning
people are in the river at
all

Even Worse:
They decide to go
upstream to find out
who is throwing people
in the river, and even
worse than that:
They decide to do
something about it.

Many Downstreamers Get
Upset with the Questioners
 Some complain that the people going
upstream are too radical. If people are
drowning, it’s their own fault.
 Others worry that trying to change
things will mean people drowning right
now won’t get helped. Their work is
important.
 But: What if drowning people stopped
floating down the river?

Many Downstreamers Say
These People are too
Radical
 The couple are told they should keep
working “inside the system,” that's how
change really happens. Don’t make
waves, even more people will drown.
 They're told not to make too much of a
fuss, it isn't polite, and funders might
decide to stop giving grants.
 The couple say they're going anyway
and start to pack.

The Downstreamers Act!
 Downstreamers hold a meeting and
decide to ostracize the couple.
 The couple load their car to go
upstream.
 Downstreamers rush the couple, grab
them, and throw them into the river.
 They float away.
Problem solved!

And Everyone Upstream
and Downstream Lived
Happily Ever After

Except for the drowning people
of course, and those who wanted
to reduce the need.

PUBLIC HEALTH IS . . .

 A shift in focus: The community,
society
 Serve individuals for community
welfare
 Community is the client
 Social model not medical model
 Physical, mental, and emotional

Context Matters
What is the responsibility of the
primary care provider? 改善

HYPOTHESIS I

If we just keep helping people at
the individual level, the needs
will be the same or worse 10, 20,
100 years from now.

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HYPOTHESIS II

The degree, extent or rate of
inequality and discrimnination
are the two most consistent
predictors of social problems

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SIX TENETS THAT
MAINTAIN INEQUALITY
Elitism is efficient (and efficiency is
good)
Exclusion is necessary
Prejudice is natural
Greed is good
Despair is inevitable, and is the goal to
assure conformity
[These conditions are sustainable]

Derived from Danny Dorling, Injustice: why social inequality persists
http://sasi.group.shef.ac.uk/presentations/injustice/ 改善

NASW ETHICAL RESPONSIBILIT Y:
SOCIAL JUSTICE & DISCRIMINATION

Pursue social change, with and for vulnerable
and oppressed individuals and groups:
Confront poverty, unemployment,
discrimination, and other forms of injustice

Not practice, condone, facilitate, or
collaborate with any form of discrimination
based on race, ethnicity, national origin, color,
sex, sexual orientation, age, marital status,
political belief, religion, or mental or physical
disability

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TO BROADER SOCIET Y
Promote general welfare of society, local to
global levels, development of people,
communities, and environments

Advocate living conditions that fulfill human
needs

Promote social, economic, political, and
cultural values and institutions to realize
social justice

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SOCIAL & POLITICAL ACTION
Engage in social and political action to ensure
that all people have equal access to
resources, employment, services, and
opportunities to meet basic human needs and
develop fully

Be aware of impact of politics on practice

Advocate for changes in policy and laws to
improve conditions to meet basic human
needs and promote social justice

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Act to expand choice and opportunity for all,
especially vulnerable, disadvantaged,
oppressed, and exploited people and groups

Promote respect for cultural and social
diversity nationally and globally

Promote policies and practices that show
respect for difference, support expansion of
cultural knowledge and resources

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Advocate cultural competence, and policies
that safeguard rights of and confirm equity
and social justice for all people

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GLOBAL SOCIAL JUSTICE
Act to prevent and eliminate domination of,
exploitation of, and discrimination against any
person, group, or class based on race,
ethnicity, national origin, color, sex, sexual
orientation, age, marital status, political
belief, religion, or mental or physical disability

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FUNDAMENTAL CONCEPT

Public health is about helping people
find ways to lead healthier lives, in every
sense.
Public health’s roots tap into social work
activism about the betterment of society.
Public health standards are divided into
three core functions further broken down
into ten essential services

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THREE CORE
FUNCTIONS

TEN
ESSENTIAL
PUBLIC
HEALTH
SERVICES

SYSTEM
MANAGEMENT

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More Lower steps can
be used to
Citizen Control influence higher
steps, e.g., therapy
Empowerment can be a tool to
raise awareness to
Delegated Power educate and

TEN LEVELS OF
Partnership empower people.

Education
Placation
Consultation

CHANGE
Informing
Therapy Modified from, Arnstein, Sherry R. Eight
Rungs on the Ladder of Citizen
Manipulation Participation. In Cahn, Edgar S. and
Passet, Barry A, eds. Citizen
Less Participation: Effecting Community
Change. New York, Praeger, 1971., p. 70. 改善

PRAXIS &
CRITICAL
COMMUNITY

Section II
EDUCATION:
EMANCIPATION FOR
EMPOWERMENT
Role of the
change agent


Community worker Community worker
seeks: raises awareness
• To gain acceptance Identify of health and social PRAXIS &
by community Felt issues, e.g., help
• Listens and Needs community CRITICAL
empathises members develop COMMUNITY
• Encourages video voice maps EDUCATION:
expression of ideas of environ-mental
Identify conditions, public EMANCIPA-
Community speaking exercises TION FOR
Success breeds
success. New needs Leaders EMPOWER-
identified by community MENT
members. They Identify root causes
develop skills and gain of social problems,
confidence to Provide
e.g.,environmental,
undertake new tasks. Supports social, economic,
Develop political
Community From: Tones. K.
Skills
Self- (2002) Reveille
Advocacy for Radicals!
Praxis: Stage of The paramount
Reflection and Action: purpose of
Establish health
Solutions identified,
Community education.
discussed, and acted on Oxford J.
Coalitions

Community Action 改
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PUBLIC HEALTH AND
COMMUNIT Y TRANSFORMATION

Show up, shut up, and

Listen
In other words,
therapists have a lot
to offer efforts to
change the contexts that
cause social problems
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WHAT WE HAVE TO OFFER THE
COMMUNIT Y

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SERIOUS INCREASES IN DISEASES AND
ILLNESSES

Exposure to toxins, pesticides, poisons
Air quality: diesel exhaust, carbon monoxide
Noise pollution (leads to decreased academic
performance)
Water pollution
Perverse incentives: Fast food
would not be cheaper without
tax incentives to produce
those types of products

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FAST FOOD NATION, FAST FOOD WORLD

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HERE’S WHERE WE GOT OFF COURSE

Since 1991 US obesity rates increased
74%.

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NAURU: MOST OBESE NATION ON EARTH
95% OBESIT Y
 Average BMI = 35 (obesity = height to weight ratio >30)

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CONSIDER THE MOST OBESE
NATION ON EARTH

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PUBLIC
HEALTH

Section VI
AND
INEQUALITY

HEALTH DATA STATISTICS: PART ONE

Millions, perhaps billions have been spent
on obesity and diabetes reduction and
treatment.
Have the numerous campaigns to reduce
the rates of obesity and diabetes been
effective?
Time period: 1985-2010 (Note: the CDC
changed its reporting methods in 1995)

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HEALTH PATTERNS

Hypothesis: The greater the degree of
inequality in a society the higher the levels of
virtually every type of social problem,
including health problems.
 Sources
 Wilkinson and Pickett. The Spirit Level: Why Greater
Equality Makes Society Stronger
http://www.equalitytrust.org.uk/
 The State of Working America
Economic Policy Institute: Working Group on Extreme Inequality
http://www.stateofworkingamerica.org /
http://extremeinequality.org/
 20 Facts About US Inequality Everyone Should Know
http://www.stanford.edu/group/scspi/cgi -bin/facts.php 改善

WORKING DEFINITIONS

Level of income disparity [inequality] in the
study was the difference between the upper
20% and the lowest 20%.
Inequality can be low one of two ways:
 Everyone is relatively rich or Everyone is relatively poor
 Examples:
 Arkansas: Low inequality, low overall income
 New Hampshire: Low inequality, high overall income
 Correlation is not causation, but . . .
 When a hypothesis can be formed, and literally dozens of measures
all point in the same direction, a case begins to emerge that two
factors that correlate consistently are likely to have a causal
relationship.


Drill Down Example
CDC DATA:
OBESITY AND
DIABETES
Case Study:
Trends in Diagnosed Obesity
and Diabetes
CDC’s Division of Diabetes Translation.
November, 2011
National Diabetes Surveillance System:
http://www.cdc.gov/diabetes/statistics

Obesity Trends* Among U.S. Adults
BRFSS, 1985
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% Note the Percentage Scale

BRFSS, 1986


BRFSS, 1987
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4”
person)


BRFSS, 1988


BRFSS, 1989


BRFSS, 1990


BRFSS, 1991

No Data <10% 10%–14% 15%–19% Note the Percentage Scale

BRFSS, 1992


BRFSS, 1993


BRFSS, 1994


Age -Adjusted Prevalence of Obesity and
Diagnosed Diabetes Among U.S. Adults

Note the Percentage Scale:
14% was the original high

Age -Adjusted Prevalence of Obesity and
Diagnosed Diabetes Among U.S. Adults

CONCLUSIONS

Growing inequality will result in increasing
rates of disease and illness
Rich developed societies have reached a
turning point in sustainability
Politics needs to become about the quality of
social relations and how we can develop
harmonious and sustainable societies.
Inequality predicts disease and illness
Focusing on individual behavior offers little
opportunity for change.

CONCLUSIONS

In brief: two main ways of reducing
income inequality
smaller differences in pay before tax
(e.g., Japan)
redistribution through taxes and benefits
(e.g., Sweden)
Economic and Political Democracy are
both necessary to improve health (US
and UK have neither right now)

WHAT IF WE REDUCED INEQUALIT Y?

Trust among people, and quality of life,
would go up 75%
Mental Illness and Obesity would drop by
65%
Teen births would be cut in half
Prison populations could drop by half
People would live longer and could work
two weeks less a year as well. Etc. . . . .

WHAT ABOUT THE RICH?

Increasing equality is good for everyone,
the rich included.
Life gets better for all: Remember,
quality of life is NOT related to income or
wealth within a society.
The rich may think they wind up better
off, but in the end they lose as well.


ARE WE

Discussion
KILLING OUR
KIDS?


WHAT’S THE BIG DEAL?

• In 1974 The Lancet identified obesity as “the
most important nutritional disease in the
affluent countries of the world.”
• Infant and adult obesity [editorial]. Lancet 1974; i:17 -18.
• What happened since then? We got fatter.
• Worldwide, we’re dying at higher rates and
nations are becoming obese.
• It’s a syndemic: Obesity, diabetes, asthma,
other related diseases are tied together.

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A NUMBER OF NEW YORKERS ARE UPSET BY MAYOR
BLOOMBERG’S SODA BAN, SAYING THAT IT IS A
CHANGE THAT WILL DRAMATICALLY EFFECT THEIR
LIFEST YLE.

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ABOUT “IT’S JUST
ONE SODA
x 365 days/year =
15 pounds of body fat
So-called “juice drinks” and
“power drinks” are just as
bad.
They all rot your teeth.
Half of Americans’ calories
come from soda. Half! 改善

ABOUT RESTAURANTS

• A typical restaurant portion size is two to
three times more than servings should be.
• We’ve been conned into measuring quality of
food in terms of quantity.
• We get far more saturated
fat and far fewer nutrients
than we should. We’re
starving while becoming
obese.

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ABOUT RESTAURANTS

• Kids get hit the hardest: They get twice as
many calories in restaurant meals than they
need.
• This simple fact yields a population of kids
that is amazingly obese, will have lifelong
health problems, and will die younger than
they should.
• Our marketing system is killing our kids, and
we’re letting it happen.

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“SPEC” MODEL:
ISAAC PRILILTENSKY

Traditional Focus Transformative Focus
Deficits-based Strengths-based
Reactive Primary Prevention
Individual & Family Empowerment
Professional-driven Community Conditions
Role shift: From “expert helpers” to “critical change agents”
Focus shift: From individual to community (context)
Power shift: From “providers” to community members
Locus of control shift: From victim to empowered actor

Http://people.Vanderbilt.edu/~isaac.prilleltensky 改善

DO OUR CURRENT HEALTH SYSTEMS
WORK?

No. If they did, we would see successes.
 “A trap we must avoid, set by the food industry [is] the
belief that education is the answer to nutrition problems.
 The ostensible rationale is that people do not understand
nutrition, that educating them will drive up demand for
healthier foods, and that the industry will be happy to
meet that demand.
 The hidden rationale is that such programs will have little
impact, allowing industry to do business as usual. I can
see industry executives jump with glee each time
government officials point to education as the answer.”
 Kelly D. Brownell. http://www.latimes.com/news/opinion/la -op-dustup19sep19,0,1026838.story

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RESULTS OF HEALTH EDUCATION

1. education has weak effects, if any;
2. it drains resources;
3. it makes industry seem on the side of
consumers; and
4. it bolsters industry's hope that government
will allow it to self-regulate while
government agencies sit on the sidelines.
5. It is the “perfect” script for public health
failure.
• K e l l y D . B r o w n e ll. h t t p : / / www. la t i m e s . c o m / n e ws / op in io n / l a - o p- d us t u p 19 s e p1 9 , 0 , 1 0 26 8 38 . s t o r y

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ABOUT INDIVIDUAL BEHAVIOR

This epidemic is about more than just
individual behavior.
Analyzing only individual behavior, assigning
blame just to each individual does not explain
the stunning change in the pattern of behavior
across individuals.
Something more than just “individual
responsibility” is going on.
(But that doesn’t let individuals off the hook!)

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QUESTIONS

So why does the US continue spend any money
at all on health information and education,
obesity prevention, healthy lifestyles, etc.,
when it clearly does not work?
If a similar pattern were experienced in any
domain – private business, government, non-
profit – what would you advise be done?
Follow the money: Who benefits from these
realities?
The Point: You have to dig deeper.
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CONSIDER

“If people want to drink 24 ounces of
soda, it’s their choice, and nobody
else’s business.”
Does social, economic, political
context have an impact on individual
behavior?
Are we “free” in some abstract way or
does the context in which we live
impact our choices?
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“CLEAN SHEET” EXERCISE

Brainstorming Context: Forget everything you
know about health, healthcare, mental health,
substance abuse, wellness, systems and
programs.
Using the core assumption: If you were free to
spend a health budget however you could,
what would you do?

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“CLEAN SHEET” EXERCISE

 If we were to create a health system from scratch
today, how would we organize ourselves and allocate
resources, and what would be our community
priorities?
 Work in small groups and develop clean sheet
systems of care. Brainstorm wild ideas as well as
practical.
 Choose a policy domain(s) of interest to your group.
 You can focus on real agencies, your own
communities, local entities, state or national policy,
your choice.

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CLEAN SHEET EXERCISE

 Try to develop something that you could work toward
in your own community.
 How would you design your approach to developing
your plan?
 Who would you talk to?
 What procedures would you use to implement your
plan?
 How would you promote it?
 What community-level indicators would you
measure?

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CORE ASSUPTION:
CONTEXT MATTERS

If we keep doing things the way we do them
right now, 50 years from (assuming the world
hasn’t imploded) the next generation will be
doing exactly the same things we’re doing
now.
Only the need will be even greater.
The more an intervention engages power
equalization, the more transformative it will
be (Isaac Prilitensky)

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DISCUSSION

Small group presentations.
What are the implications of using the NASW
standards and to reform the helping
professions, health care plans in this case?
15 minute small groups, design a broad
intervention strategy.

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ADDITIONAL REFERENCES

 B un ke r JP, Fra z i er H S, M o s teller F. Im prov i ng h e a lt h: m e a suring e f fe c t s o f
m e di c al c a re . M i l ba nk Qua r te rl y 1 9 9 4 ; 7 2: 2 25 - 5 8.
 B o l en JR, Sl e et DA , Ch o rba T, et a l . Ove r view o f e f fo r t s to preve n t m oto r
ve h icle - relate d i n jur y. In : P reve nt ion o f m oto r ve h ic le -rela ted i n j uries: a
c o m pe ndium o f a r t i c l es fro m t h e M o rbi di t y a n d M o r t a l it y We e kly Re po r t , 1 9 8 5 -
1 9 9 6 . At l a n t a, G e o rg ia: US D e pa r t m e nt o f H e a l t h a n d H um a n Se r v i c es, Ce n te r s
fo r D i s ease Co n t ro l a n d P reve n tio n, N a t i o nal Ce n te r fo r In j ur y P reve nt ion a n d
Co n t ro l, 1 9 97.
 H oye r t D L, Ko c h a ne k K D , M urphy SL. D e a t h s : fi n a l da t a fo r 1 9 97. H ya t t s ville ,
M a r y l an d: US D e pa r t m e nt o f H e a l t h a n d H um a n Se r v i c es, CD C, N a t i o n al Ce n te r
fo r H e a l t h St a t i s tic s, 1 9 9 9 . ( N a t ion al v i t a l s t a t ist ic s re po r t ; vo l 47 , n o . 2 0).
 CD C. Fa t a l o c c upa t i onal i n juri es - - Un i te d St a te s , 1 9 8 0 - 1 99 4. M M WR
1 9 9 8 ; 47: 2 97 - 30 2.
 An o nymo us. Th e s i x t h re po r t o f t h e Jo i n t N a t i o nal Co m mit tee o n P reve nt ion ,
D ete c t i on , E va lua t ion, a n d Tre a t m ent o f H i g h B l o o d P re s sure . Arc h In te rn M e d
1 9 97 ; 157: 241 3 - 4 6.
 B ur t B A , E k l und SA . D e n t ist r y, de n t a l pra c t i c e , a n d t h e c o m mun it y.
P h i ladelphia , Pe n n sy lvania: WB Sa un de r s Co m pa ny, 1 9 9 9 : 2 04 - 2 0.
 P ubl i c H e a l t h Se r v i c e. Fo r a h e a lt hy n a t i on : ret urn s o n i nvest ment i n publ i c
h e a lt h . At l a n t a, G e o rgia : US D e pa r t m e nt o f H e a l t h a n d H um a n Se r v i c es, P ubl i c
H e a l t h Se r v i c e, Of fi c e o f D i s ease P reve nt ion a n d H e a l t h P ro m ot ion a n d CD C,
1994.


CONTACT FOR MORE INFORMATION

About this presentation:
Daniel Jordan, PhD, ABPP at
publichealth@iugrad.edu.kn
About the International University for
Graduate Studies graduate
programs:
www.iugrad.edu.kn


Public Health: Myths and Realities

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