Monday, July 19, 2010
Saturday, July 17, 2010
I stepped outside my apartment today and stumbled upon the 12th Annual Harlem Book Fair only a few blocks away. Tents lined 135th Street with book sellers and authors hawking their words and prose. It was not surprising that most of the books catered to the population in Harlem – Urban fiction, Black Literature and books on social justice dominated the tables. I wandered past the AK Press booth and picked up a copy of Urban Injustice: How Ghettos Happen by David Hilfiker, MD (Seven Stories Press). Hilfiker presents a history of the social structures that created ghettos and keep African Americans from rising out of poverty. His experience comes from practicing as a physician in a medical recovery shelter for homeless men in Washington, DC and cofounding a community and hospice center for formerly homeless men dying of AIDS.
I chose this book because it expresses the mission of this blog: Create an argument for social equality to promote the health and wellbeing for those affected by injustice. Future posts will analyze chapters from this book and comment on my own experiences and opinions.
Tuesday, July 13, 2010
Today Kathleen Sebelius, Secretary of Health and Human Services, announced a new national strategy to fight the HIV/AIDS epidemic. Early in his administration President Obama organized a committee to consult doctors and persons living with HIV/AIDS, researchers and health workers, activists, community leaders and academics to develop a plan with three goals:
1) reduce the number of people who become infected with HIV; 2) increase access to care and improving health outcomes for people living with HIV; and, 3) reduce HIV-related health disparities.
The vision is that “The United States will become a place where new HIV infections are rare and when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity or socio-economic circumstance, will have unfettered access to high quality, life-extending care, free from stigma and discrimination.” Said Secretary Sebelius.
The Strategy calls for a 25% reduction of HIV prevention over the next five years. In order to achieve this objective the administration acknowledges it must target the populations at higher risk. The disparity between HIV infection and treatment is drastic in the United States as Sebelius explains:
“we’ve been very successful at keeping HIV/AIDS incidence low for some populations. If you’re a white, heterosexual woman like me, your chances of being infected by HIV/AIDS are very low – just 1 in 50,000. But if you’re a black female who’s an injection drug user, your chances of being infected are more than 1,000 times higher – closer to 1 in 35. If you’re a gay Hispanic man, your chances are 350 times higher. In some U.S. cities, it’s estimated that almost half of all gay black men are HIV-positive.” Read her full speech.The Strategy is praised for its ambition and thoughtfully outlining a road map with milestones and targets.
However, Michael Weinstein, president of the AIDS Healthcare Foundation, was critical of the Strategy: "This strategy is a day late and a dollar short: 15 months in the making, and the White House learned what people in the field have known for years. There is no funding, no "how to," no real leadership." Said Weinstein, "Access to care for HIV is declining in this country. You can't say this is a new strategy, if you don't intend to spend any money on it."
Charles King, president and chief executive officer of Housing Works which tries to ameliorate the problem of AIDS and homelessness, was also disappointed. A snippet from a Housing Works press release:
“The president’s plan is so flawed that it might actually represent a step backwards in combating HIV and AIDS in the United States,” said Housing Works President and CEO Charles King. “Since his days on the campaign trail, President Obama has repeatedly said that he wants to lead the fight against AIDS. Unless he commits significant new resources intended to make major inroads against the spread of HIV, he will be regarded as a leader who did next to nothing about the most devastating epidemic of our time.”
Saturday, July 10, 2010
Alan Aderem was featured in last week's Seattle Times for his work as a biologist and activist. He is the co-founder of the Institute for Systems Biology in Seattle and has dedicated his life to developing an HIV vaccine. Aderem was raised in South Africa under the dominion of apartheid. His experiences growing up fighting for equal rights left an indelible impression that has guided his politics and career in biology.
Monday, July 5, 2010
Saturday, July 3, 2010
Our health is a reflection of the experiences in which we are born, live, work and age. Fundamentally, our experiences are shaped by the distribution of resources and power which are controlled by policy choices. The wealthy have more resources often at the expense of the poor. This means our social status determines our overall health. Unequal distribution of resources leads to health inequalities.
Clearly individual behaviors, such as practicing unsafe sex and drug use, place the individual at a greater risk for disease transmission. However, the distribution of infectious disease is influenced by social determinants that put in place systems to deal with the prevention and control of illness. Historically, programs primarily focus on individual-level interventions as it has been thought that health is the sole responsibility of the individual. Understanding the patterns of disease and their social determinants allow us to create more effective and efficient programs and policies.
In 2005, the World Health Organization established the Commission on Social Determinants of Health to investigate the factors that produce health disparities and develop strategies to reduce them. Their final report, published August of 2008, suggests three recommendations (in summary):
- Improve daily living conditions: (a) The best possible way to improve living conditions is to invest in early childhood development. This will see that more children are reaching their potential and have a positive influence on the health of society. (b) Now that more people in the world are living in urban settings consequently means more people are living in urban slums. The commission calls for greater availability of affordable housing, clean water, sanitation and electricity. Also, social programs to reduce violence and crime are essential with people living in closer proximity to each other. (c) Fair employment and wages provides financial security in addition to personal development and self-esteem. And all people should be protected from unforeseen disruptions such as illness, disability or loss of income. This includes a policy for universal healthcare to promote good and equitable health coverage.
- Tackle the inequitable distribution of power, money and resources: The commission calls for health equity to be a marker for government performance of wealth distribution. They suggest a progressive tax, increased global aid and legislation to ensure all groups in society have equal opportunities and representation.
- Measure and understand the problem and assess the impact of action: A well calculated assessment ensures that action is effective and efficient so as to provide better policies and programs. The public, civil and private sectors should understand and be responsible for the role they play to promote a healthy society.
The former US Surgeon General, Dr. David Satcher, calls for a new way of thinking about health. Public health professionals and the federal government need to address social determinants and frame their work around health equity. In the late 1950s Dr. William Foege reviewed the death certificates of the Seattle-King Country area in order to understand the health of the population. He noted the fallacy of this method:
‘While death certificates might list heart attacks or cancer, cigarette smoking is responsible for one in four deaths, but tobacco use is rarely indicated on death certificates. Factor in diet and alcohol consumption, and we can account for 40% of deaths. Studying death certificates is a poor way to understand what is really happening to a population’s health.
The real causes of many deaths are social determinants such as illiteracy, fatalism, gender bias, racial bias, unemployment, and poverty. Poverty is the single biggest factor contributing to adverse health outcomes, and health outcomes worsen as poverty becomes more severe. In 1424, Hongxi, emperor of the Ming Dynasty in China, who himself grew up in poverty, said, “We must treat poverty like we would treat drowning. There is no time to lose.”’
Friday, July 2, 2010
The social determinants of health require us to think about health in a way that goes against accepted ideology. We are told diet, exercise, smoking and condoms are the factors that affect our health. While these factors are important for the health of the individual little emphasis is placed on the caring and sharing within a community. Studies show that a hierarchical society, like our own, produces a chronic stress response in the subordinate classes.
To deal with a stressful situation the body's sympathetic nervous systeminduces the "fight or flight" response. This mobilizes the endocrine system to produce the stress hormones Growth Hormone (GH), Cortisol, andnorepinephrine & epinephrine (adrenaline). An acute stress response is beneficial to our health as it prevents us from getting hit by a car (or a taxi if you live in NYC). However, chronic exposure to the stress hormones can lead to a laundry list of health problems:
- Stress hormones antagonize the ability of insulin to reduce blood glucose thus contributes to hyperglycemia.
- Cortisol along with norepinephrine & epinephrine play an important role in inflammation and immune homeostasis. Cortisol inhibits phospholipase A, a key enzyme in the mediation of the inflammation response. Cortisol also compromises the immune system by decreasing the number of helper T lyphocytes. An anti-inflammatory and immunosuppressant response is an essential strategy when fighting an infection suddenly is less of a priority than out running a lion. However, this has the potential to do significant harm when the body is not able to attend to an injury or infection for a prolonged period of time.
- Cortisol and epinephrine are involved in the creation of short-term memories, however chronic exposure may damage the cells of the hippocampus and impair the ability to learn.
- Reproductive behavior is reduced in response to stress. Cortisol inhibits the reproductive axis of the endocrine system.
- Our muscles contract when calcium ions are released into the muscle cell. Our bones are our calcium reservoirs and cortisol increases bone resorption (break down of bone) to provide more calcium to the muscles. Again, think "fight or flight." However, too much cortisol over a long period of time leads to decreased bone density and osteoporosis.
- Cortisol and GH are involved with lypolysis (break down of fat) thereby making free fatty acids available as energy sources. However, this fat gets redistributed around the visceral organs.This means increased abdominal fat which can lead to heart disease among other problems.
- Cortisol also shows strong, consistent relationships with obesity factors.
- Excessive levels of cortisol initially produces a feeling of well-being but continued exposure eventually leads to emotional lability and depression.
In order to reduce stress the common suggestions are: breathe to relax, exercise, practice mediation or yoga, sex, music, etc. However, these strategies do nothing to mitigate the stress caused by social hierarchies (with exception of sex as we will see). Subordinates in such a society have less control and routine to their daily lives. Additionally, they have less protection from unforeseen disruptions such as illness, disability or loss of income. This allows for a very stressful environment. However, those who have more friends - those who practice more caring and sharing do better at managing their stress. Friends, in a sense, are protection from life's catastrophes. The reassuring feeling to know that you have a couch to sleep on if you lose your house or you can borrow some money if you're pinched for cash helps to reduce an otherwise stressful situation. One can imagine sex is involved in building relationships with others and thus also helps to reduce stress. This was demonstrated in a study where male baboons more involved in consortships had lower basal cortisol levels than their more threatening rivals.
The next post will discuss how to reduce hierarchies and create a more egalitarian society in order to close the gap in health inequalities. Until then, be fruitful and multiply.
Thursday, July 1, 2010
Much of the world is making strides to reduce child mortality according to a study published last month in the Lancet. It is estimated that 7.7 million children this year will die before the age of five. This number is more than 35% lower than the 11.9m child deaths of 20 years ago. The Millennium Development Goal #4 is to reduce the mortality rate of children under five by two thirds by 2015.