Tag Archives: Advocacy

Family Caregiving—A Public Health Crisis

Caregiver in scrabble text.
Photo credit: Flickr, Michael Havens.

This last year was the hardest one of my life. And I’m writing a blog about it because my personal experience is a public health issue.

In the midst of taking vacation time off to help my 80-year old mom move into a retirement community, the St. Louis Dispatch released an article about the health impacts of caregiving for elderly parents. The article notes that adult children who are caring for elderly parents have a myriad of poor health outcomes themselves—stress, higher rates of chronic disease, social isolation, and economic harm.

I relate. My mom’s move came about 6 months after my father died after a lightning-quick struggle with stage 4 lung cancer. During the last year, I have experienced everything covered in the National Academies of Sciences, Engineering, and Medicine (NAS) report, Families Caring for an Aging America: lack of exercise, poor eating habits, lack of sleep, incredible stress, extreme difficulty navigating our insane medical care system, and lack of support in how to set up my mom’s new life. Tearfulness, depression. My brother, in commenting on the difficulty of the last year, said, “I see now why it is very common that people die within one year after their spouse dies.”

The NAS publication cautions that our society is dependent on family caregivers. Nearly 14% of the US adult population has been a caregiver for an aging adult in the last year, and that is a role that typically lasts 5 years or more.

So. My personal experience raises two public health issues. The first—as noted—how we need to get on it to deal with the dearth in support for family caregivers, or train and pay (and pay very well!) an army of caring people to help our aging population. Policies like the Domestic Workers Bill of Rights in New York and 5 other states newly support domestic workers’ rights to minimum wage, overtime pay, and other worker protections. The organizing efforts of the National Domestic Workers Alliance brought together family caregivers alongside the people they care for—people with disabilities, families with young children, and elderly people like my mom. Both domestic workers and the people who pay them understand that better working conditions will help ensure that our families are well cared for.

In addition to paid caregivers, sometimes we need to take time off to provide care directly. Only four states—California, Rhode Island, Washington, and New Jersey—and the District of Columbia have Paid Family Leave policies to help people take extended time off to care for their families. My own state of Massachusetts tried to pass a Paid Family Leave law earlier this year, which would have required employers to offer up to 16 weeks of leave for family care, with a portion of salary paid out of a state fund. Unfortunately it got blocked in the State House, so like the majority of the US, I still do not have access to these benefits.

So instead I took vacation time to take care of my mother. I can tell you, my time off was no vacation.

A Framework Connecting Criminal Justice and Public Health

HIP has been doing a lot of research about how criminal justice policies and practices affect health. As our work to understand these impacts has evolved, we are more and more convinced that it is a public health imperative to use the power of public health to re-envision and change our justice system and virtually all its component parts.

As conveners of the National Criminal Justice and Public Health Alliance, we’ve also been thinking a lot about how the determinants of health are more or less the same as the determinants of justice system involvement. Others are also thinking about criminal justice as a public health issue by: changing behaviors related to violence; addressing the traumas that victims face and how those perpetuate crime; reducing Adverse Childhood Experiences; ensuring those leaving prison sign up for Obamacare; and working to reinvest savings from criminal justice reform back into our hardest hit communities.

All these approaches are necessary to addressing the health and social needs of those who are justice involved. It’s useful to also think about how these individual and community level interventions tie together into a criminal justice and public health framework. This diagram represents a way of thinking about these relationships and how change in any one domain might affect change in another domain.


First, let me give examples of what is included in each element of the diagram:

  • Community Conditions – Social, Economic, and Environmental Determinants of Health includes employment, housing, and education; exposure to environmental contaminants like lead as well as access to healthy food; and poverty, racism and other forms of oppression, and empowerment.
  • Physical and Mental Health Outcomes includes chronic disease (e.g., cardiovascular disease, diabetes); infectious disease (e.g., AIDS, hepatitis); developmental issues; stress, anxiety, depression, and trauma; and preterm birth, infant mortality, and premature mortality.
  • Behaviors include substance abuse, theft, and violence as well as eating a healthy diet and getting exercise.
  • Criminal Justice System Involvement / Criminal Justice Policies includes involvement in system as well as policies that govern all aspects of the criminal justice system including school discipline and the school-to-prison pipeline; policing; pre-trial, prosecution, defense, adjudication, and sentencing; incarceration; and release and re-entry.

Here are some examples (though not a comprehensive list) of how elements of the framework shown in the diagram simultaneously interact with each other to generate poor health and justice system involvement.

Examples: How factors that shape health affect justice involvement, behaviors, and health outcomes

Determinants of health can affect criminal justice involvement, behaviors, and physical and mental health outcomes through:

  • Homelessness and poverty are criminalized, leading to justice system involvement
  • Both structural and institutional racism lead to over-policing of black communities and disproportionate punishment of people of color throughout the justice system.
  • Lead exposure in childhood leads to developmental delays, behavioral issues, and crime.
  • Unemployment can lead to a host of behavioral issues: drug use, involvement in the underground economy, theft, and various forms of violence.
  • Conditions that lead to Adverse Childhood Experiences, such as exposure to violence in the community, homelessness, or incarceration of a parent, can lead to behavioral issues in school and beyond, substance abuse, as well as mental health disorders.


Examples: How justice involvement affects factors that shape health and health outcomes

Criminal justice involvement and policies can affect determinants of
health, behaviors, and physical and mental health outcomes through:

  • People re-entering society face collateral consequences of justice system involvement, such as difficulty finding employment and housing.
  • Experiences while incarcerated, including traumas from physical, sexual, and mental abuse, and from isolation, can lead to drug use and further violence.
  • The presence or absence of rehabilitative programs while incarcerated influence recidivism upon release.
  • Restorative justice practices as an alternative to incarceration influences


Examples: How health outcomes affect justice involvement and factors that shape health 

Physical and mental health outcomes can affect criminal justice involvement and determinants of health through:

  • Physical or mental health issues can lead to unemployment and housing instability.
  • Mental health crises can lead to arrest.
  • Debt from health care expenses can lead to inability to pay bills, poverty, and arrest.




How can this framework be used?
This framework provides public health and criminal justice reform advocates a common basis for talking about work to create a more just criminal justice system that creates the conditions necessary for people to succeed and therefore healthy and safe communities. Those seeking change in any element of the framework should recognize that their efforts are linked to other elements and therefore a) consider the relationship and consequences of their work on those other elements and b) build relationships with others working on other parts of the framework to think about how all efforts can reinforce one another. The less our work is isolated, the better the outcomes we will realize.

For example, many proposed criminal justice reforms can be analyzed using this framework. Our Health Impact Assessments ask how these reforms – in policing, sentencing, access to education in prison, for example – influence physical and mental health outcomes directly, and through changes in the other two elements – behaviors and determinants of health.

As we continue work with the National Criminal Justice and Public Health Alliance, we’ll make sure we represent the different aspects of the framework in our discussions and continue to strengthen relationships between the groups doing this work. We have already collaborated to create a vision for a criminal justice system that operates from public health principles. Should this vision be realized, it would improve upon virtually all elements of the framework and lead to improved health and justice system outcomes.

We hope the framework is useful to others doing work at the intersection of criminal justice and public health. We’d love to hear your thoughts!

Public Health Advocates – Stop Waiting for Evidence about Gun Control!

In public health, especially government-run public health departments, we often debate whether there is “enough” evidence, or whether the evidence is “robust” enough, to justify speaking out and becoming an advocate on a particular issue. A bill in the California legislature right now would fund a Gun Violence Research Center at University of California at Davis if passed – a welcome addition. However, pioneering researchers have already provided scientific evidence that indicate there is no reason for public health practitioners to tiptoe around this issue.

Guns lead to death and injury. You don’t need a study to know this. There is a mantra that the National Rifle Association perpetuates, that even Michelle Obama has echoed, that there are instances in which it is justified for someone to own a gun to make the gun owner safer.

Well, owning a gun is dangerous and does not make you safer. It actually increases the chance that the gun owner or a family member will die or be injured (see links to that evidence below), and the number of guns per capita in a country is a predictor for the number of firearm-related deaths. And despite a ban that muzzled the Centers for Disease Control and Prevention (CDC) from doing research on guns (which was lifted in 2013 but not funded), academics have been doing the very difficult work of studying the impact of owning guns and policies and practices that limit or ease gun ownership.

The increase in risk of gun owners being injured or killed – compared to people who do not own guns – has been proven in several epidemiological studies that control for factors that might make gun owners at higher risk, such as area levels of violence, unemployment, urbanization and other factors. Some studies looked at keeping guns in the home, and found the same results: a higher risk of being harmed by guns among those who own guns. Yet the NRA’s claim is that any law to make restrict gun access will hamper the ability of law-abiding citizens from owning a gun. And Americans, despite the evidence, believe it.

I’m just going to say it again, though: By owning a gun, you are 4.5 more likely to be shot by a gun. And every single case-control study conducted has found that gun ownership is a strong risk factor for suicide. In fact, more than 60% of the firearm-related deaths are suicides.

A recent HIP study considered the health impacts of police purchasing “smart guns”, which only operate when activated by a biomarker (such as a fingerprint) of the owner. The study showed that between one-third to over one-half of the deaths by firearm could be prevented – this is homicides and suicides, and includes deaths from guns shot by children, by those who steal legally purchased guns, and guns taken from police. Based on 2013 deaths by firearm, this means between 9,400 to 17,200 deaths could be averted.

The data and evidence are out there. Webster, Vernick and Wintemute have studied the impact of policies to keep firearms away from high-risk individuals; Wintemute has shown that it is possible to take guns away from those who have been arrested and convicted of domestic violence or have a restraining order; Anestis and Anestis have found that laws that limit access to guns decrease suicide deaths. Irvin, et al studied the impact of regulating firearm dealers, finding that states requiring licensing and inspection have lower homicide rates. These brave researchers have bucked significant pressure to look away from these life and death questions.

In some cases the data can be flawed. For example the Department of Justice’s reporting of civilians killed by law enforcement was viewed as so unreliable that news source’s such as the Guardian and The Washington Post started collecting and analyzing their own data on police killings.

If public health practitioners consider themselves advocates for health – and consider themselves opposed to death and injury – there is truly plenty of excellent evidence that makes it imperative for us to stand up, call ourselves advocates for reducing gun ownership, and speak out.

Building Hope with Community: The Right to Affordable Housing in South Central Los Angeles

This week’s blog is a repost from Esperanza Community Housing. The post discusses the right to affordable housing in South Central Los Angeles and preliminary findings from HIP’s HIA on a development in the area

The narrative of South Los Angeles has been one of serial displacement. Community residents, primarily low-income people of color, have systematically been priced out of our homes and neighborhoods to make way for industry and for gentrifying trends. We’ve faced higher rents, skyrocketing property values, and a cost of living that has become unmanageable — even when working multiple jobs. This combination is a result of the city’s poor planning and spot-zoning policies, and the real estate development industry’s unchecked pursuit of profits without consideration of the human cost of housing, health, and security. This has put not only our homes at risk, but also our health, our identities, our livelihoods, and our environment. Read more…

Does Organizing Have a Place in Public Health?

Many social movements in the United States have used community organizers to mobilize and strengthen collective power to liberate communities from systems of oppression. Today, the concept of “organizing” is becoming mainstream as we watch Black communities unite to address police brutality and reform the criminal justice system.

Some people relegate “organizing” as an advocacy strategy to push a single-issue, minimizing the historical impact. I consider organizing a strategic process that brings together community to influence institutions, policies, and government through relationship building and education.

The purpose of public health is to protect the health of individuals and communities from harmful conditions in the workplace and the environment where they learn and live. With public health’s unique focus on improving the health of populations, the field has set workplace safety standards, enacted policies to ban smoking indoors, and created nutrition programs in schools. These are all institutional, policy, and government changes; the same kind of changes influenced through community organizing. By organizing and framing issues as a public health matter, our profession has been able to elevate the health of communities.

Historically, communities have relied on their own power to organize against injustices they were experiencing and/or witnessing. The long history of organizing is rooted in changing structural systems to grant civil liberties to those who have been marginalized. Ella Baker, a community organizer during the Civil Rights Movement, was a leader in collective leadership development. Rejecting the need for a charismatic leader and formal hierarchy, Baker preached, “In order for us as poor and oppressed people to become part of a society that is meaningful, the system under which we now exist has to be radically changed…It means facing a system that does not lend its self to your needs and devising means by which you change that system.”

My own experience with organizing started while I was a public health student in Seattle, Washington. I worked closely with Ending the Prison Industrial Complex (EPIC), a coalition organizing to prevent the building of a new youth jail. Organizing around mass incarceration helped me to understand the intersectionality between systems of oppression and health outcomes.

Over the past two years, I’ve been on the ground working with EPIC to bring public health analysis to the No New Youth Jail campaign. EPIC uses ten anti-racist principles from The People’s Institute for Survival and Beyond to transform communities by providing political education to understand their power and hold elected officials accountable. During my time with EPIC, I along with other public health students expressed our strong opposition and challenged city council members to consider their support of the jail as being in direct contradiction with the goals of protecting our youth. We highlighted the health consequences of incarceration; beyond individual health, we talked about community and economic effects like the high costs associated with incarcerating youth, the justice system’s perpetuation of racism and discrimination against Black and brown youth, and incarceration’s inability to solve the underlying problems of communities.

Because of our strong organizing, we garnered support from one city council member, Kshama Sawant who voted “no” to investing over $200 million dollars in building a detention center. The persistent pressure from organizing groups and community did not end even in the face of adversity. Modeling alternatives and changing the narrative of incarceration, a resolution to end youth incarceration was written with the support of EPIC and Youth Undoing Institutional Racism. On September 17, 2015, the City Council’s Public Safety committee voted to end youth incarceration in Seattle and now the measure will go to the city council for approval.

The fight to end youth incarceration is far from over. Patrick McCarthy, CEO of Annie E. Casey Foundation in June 2015, urged states to close down youth prisons. “We need to admit that what we’re doing doesn’t work, and is making the problem worse while costing billions of dollars and ruining thousands of lives,” said McCarthy.

On the ground organizing is pushing elected officials to consider the unfair treatment of Black and brown people from early childhood to adulthood in school, employment, housing, criminal justice system, and other sectors. Public health has a unique opportunity to use anti-racist community organizing principles to frame issues to radically transform the living conditions and opportunities for communities.

Climate Action is Health Action: Why Support for California Climate Legislation is Good for Our Health

This week’s blog was originally published by the Public Health Institute (PHI) on August 25, 2015. 

“Amid a historic drought that has been linked to climate change, California’s state legislature is currently considering bills that aim to significantly reduce greenhouse gas emissions in the coming decades. Often considered a bellwether in American politics and a global leader in combating climate change, California’s proposed bills could provide a model for other governing bodies to set similar goals at local, state and international levels. This year, the state’s governor, Jerry Brown, assembled state-level governments from around the world to sign a commitment to match California’s proposed target for reducing emissions. The U.S. government also recently announced a Clean Power Plan that echoes California’s groundbreaking 2006 climate change legislation.” Read more… 

If Black Lives Matter, We Can’t Stay on the Sidelines

Let’s not sit on the sidelines.

With those words Dr. Mary Bassett, health commissioner of New York City, in a Perspective for The New England Journal of Medicine clearly and boldly declares that health professionals are accountable for fighting interpersonal and institutional racism, because of the undeniable truth that racism contributes to poor health outcomes.

In “#BlackLivesMatter: A Challenge to the Medical and Public Health Communities,” Dr. Bassett acknowledges that “tackling racism is daunting” and for many in the health community “often viewed as divisive and requiring action outside our purview.” She calls out the “dearth of critical thinking and writing on racism and health in mainstream medical journals,” pointing out that over the last decade only 14 articles in NEJM even contained the word racism. And she lists three ways we can – and should – make a difference:

  • Research: “By studying ways in which racial inequality, alone and in combination with other forms of social inequality (such as those based on class, gender, or sexual preference), harms health, researchers can spur discussions about responsibility and accountability. Who is responsible for poor health outcomes, and how can we change those outcomes?”
  • Internal reform: “Our target ‘high-risk’ communities, often communities of color, have assets and knowledge; by heeding their beliefs and perspectives and hiring staff from within those communities, we can be more confident that we are promoting the right policies.”
  • Advocacy: “Some [health professionals] may choose to participate in peaceful demonstrations; some may write editorials or lead ‘teach-ins’; others may engage their representatives to demand change in law, policy, and practice.”

Right on! These actions align completely with HIP’s new strategic direction – research, advocacy, and capacity building to bring the power of public health science to campaigns and movements for a just society. They also align with the work members of our Public Health and Equity Cohort are doing to advance racial and other forms of equity in their health agencies and communities, with an inside-outside strategy for change. And they reflect the way we do our work at HIP and what we advocate that other health professionals should do in their work.

Dr. Bassett is right. Addressing structural racism is hard. But we can’t sit this struggle out. Let’s remember why we’re in this: to improve health and reduce health inequities. We can’t back off when that means we must confront racism.

Paid Sick Leave: Health Advocates Can Help Win A Common Sense Policy

By HIP Co-Founder Rajiv Bhatia, M.D., originally posted at HealthBegins:

Imagine waking up sick with the flu. Wouldn’t you want to take a day off from work? What if not working meant going without pay? What if your boss has been reminding you about the value of reliability?

After July 1, 2015, fewer California workers will have to struggle with this choice. Last week, California Governor Jerry Brown signed AB 1522 making California the second state (after Connecticut) to guarantee most workers some paid sick leave.

Read the full article at at HealthBegins.

Am I a Scientist or an Activist?

For a recent graduate of a master’s in public health program, Human Impact Partners’ Health and Equity Fellowship was a golden opportunity to put those three little letters at the end of my name to good use. Health Impact Assessment combines both analytic rigor and a participatory, community-driven approach to promote health, equity and justice. So on my first day at the HIP office, I had to ask myself: Am I a scientist or an activist?

As a biology undergrad researching the genetics of virulence in human-parasite interactions, I was squarely in the scientist camp. As a public health graduate student, participating in city council meetings to support changes to Oakland’s rent ordinance to protect low-income tenants, I was treading into activist territory. At various points I’ve identified more strongly as one or the other as these split personalities played a constant tug-of-war.

Now, almost two months into the fellowship, it seems that these two sides of me are pulling in the same direction. Health Impact Assessment – the HIP way – is both science and activism.

Public health has always been a complex field, but in the last decade our definition of public health has expanded so rapidly that it seems to burst at the seams every few years, challenging us to adopt ever more expansive and rigorous frameworks to address the full scope of the issues it encompasses. Public health’s scope has expanded from contagion control to prevention to behavior change and more recently to social justice. Given these changes, it seems that the reach of science is simply no longer expansive enough to encompass that scope on its own. Nor are traditional scientific approaches rigorous enough. Public health needs to look more like advocacy and community organizing to remain relevant to the populations it seeks to benefit.

In graduate school at UC Berkeley, I found myself working to promote the health of undocumented immigrant Latino day laborers. I did this in part through ethnographic research, direct services to help meet day laborers’ basic needs and educational sessions on occupational health — all part and parcel of traditional public health practice. But that alone was not enough. It was only a start.

How do you take control of your own well-being when your health is hugely influenced by a city ordinance that prevents you from seeking work and wages to support your basic needs and those of your family? How do you ensure on-the-job safety when your labor is simultaneously a highly sought-after commodity and a political lightning rod for anti-immigrant sentiment?

These issues, and many others like them, are complex and yield no easy answers. HIP’s combination of public health and social justice frameworks help us ask better questions and use the evidence to tip decisions in the direction of health and social equity, and to empower communities to make change happen.

I’m humbled at the challenge of working with the talented team of smart, motivated professionals at HIP — already, I have learned so much, and hope I can contribute as much as I receive. And I’m privileged to work in solidarity with communities and be a part of movements to make good on the promise of health for all.

HIP is pleased to welcome Darío Maciel as HIP’s 2014-2015 Health and Equity Fellow. As one of our strategies to advance health and equity in decision-making, HIP offers a yearlong, fulltime Fellowship for an emerging public health professional, with a goal of increasing the racial and ethnic diversity among practitioners of Health Impact Assessment and Health in All Policies approaches.

Analysis: ‘Willful Defiance’ School Suspensions Have Health Impacts

We are re-posting an April 29, 2014 Reportingonhealth.org blog by Celia Harris.

In the 2012-13 school year, almost 260,000 student suspensions in California public schools — more than 40 percent of the total — were for “willful defiance” of authority. Willful defiance was the single most common reason for suspension and more students were suspended for willful defiance than for drugs, weapons and violence combined. Read more…