Tag Archives: Ethical Use of Evidence

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.

Confessions of a Former Victim-Blamer

I admit it. I used to be a professional victim-blamer. I didn’t realize it at the time and I always meant well. But as a public health educator, I sometimes contributed to people blaming themselves for their own poor health – because I didn’t mention to them how hard it might be to do the things I was telling them to do, or that there might be other things that could be done to improve their chances. This probably left them thinking that if they didn’t succeed, it was their fault.

An overwhelming majority of Americans blame people, and people blame themselves, for being fat because they don’t eat right or get enough exercise. We in the public health community tell them about all the ways obesity will harm their health. Then our society, from the medical establishment to reality TV, perpetuates this message (even though the relationship between weight and health is more complicated than that). In my days as a public health educator, I toed the party line and supported efforts to encourage individuals to change their eating and exercise behaviors to maintain a healthy weight.

When people live in neighborhoods that lack safe sidewalks, bike paths, parks, or public transit they can walk or pedal to, they’re naturally less likely to be physically active. And when people don’t have easy access to affordable healthy food, but are surrounded by corner stores, gas stations, fast-food places, and food industries pushing cheap unhealthy food, guess what? They’re less likely to make healthy choices. While the public health community is now supporting some neighborhood and policy interventions, most of our messages about food and exercise still focus exclusively on the individual without information about the influence of the environment, which probably contributes to a lot of the blaming mentioned above.

Victim-blaming can also result from the way we talk about sexually transmitted diseases. I cringed when I heard an NPR story reporting that when people are told how bad STDs such as herpes are, they are less likely to want to get tested and find out if they’re infected. I used to be one of those people who did condom demonstrations on plastic bananas and then handed out brochures with scary pictures of what might happen if they didn’t use them.

These messages, like the ones about healthy eating and exercise, were focused exclusively on the actions individuals should take, without any context about how the environment might influence their choices. When we use messages that talk about the bad or scary things that can happen to people in an effort to motivate them to change, the underlying message can easily become if you don’t do these things to protect your health, you deserve it if you get fat or get an STD – leading people to blame themselves, and others to blame them as well.

But again, look at the neighborhood. If you live in a neighborhood where there’s nothing for teens to do after school, a neighborhood where there aren’t enough jobs so people resort to selling drugs, a neighborhood saturated with alcohol advertising, you have a higher chance of contracting an STD. Neighborhood factors can create a vicious cycle. In some urban neighborhoods more than half of the young men have been in prison, most often for selling drugs. Prison gives them a higher exposure to STDs. With so many of them locked away, people in the neighborhood have fewer partners to choose from, so those who have STDs are more likely to share them with others.

There was even some level of victim-blaming when I taught stress management, though perhaps this was more subtle. For nine years, I taught patients in an outpatient clinic of a hospital that primarily served a low-income African American population how to manage stress. I offered them guidance in different forms of meditation and ways to change their thoughts. It was deeply rewarding on one level – I loved hearing things like “My family says I smile more now!” – but I worried that people would not be able to sustain the benefits long-term, and eventually I came to see it as putting a Band-Aid over a bigger, deeper problem.

The fact is that poverty and racism are stressful. Learning how to manage your own stress does nothing to get rid of the root causes, and when you are surrounded by root causes that never go away, you must continually swim upstream to take care of yourself, and may blame yourself if you don’t succeed. Meanwhile, policies that work to reduce the impacts of poverty, such as minimum wage laws and wage theft ordinances, are a different way to tackle stress at the population level.

I’m not saying we should stop talking about the importance of physical activity, healthy food, safer sex, and ways to manage stress. And I’m not saying messages directed at individuals are inherently victim-blaming. But I am saying that when we know neighborhood and policy factors influence individual behaviors and we only tell people about the individual behaviors they should change, it can lead to moralizing about those behaviors and to victim-blaming.

In the systems thinking world, some might call victim-blaming an unintended consequence of individually-focused prevention messages. It’s time to recognize and address this unintended consequence by complementing those messages with information and advocacy for public policies that promote health and well-being. It’s time to stop fanning the flames to blame the victim and work together to change the conditions that lead to poor health.

Public Housing, Public Health and the Public Interest

This blog post was originally published at The Pump Handle on February 18, 2014.

The quality of public housing is a key determinant of health among low-income populations. Substandard housing – where mold, pest infestations, fire hazards, or other health risks are present – is associated with a wide range of health problems, including respiratory infections, asthma, lead poisoning and mental health issues. Nor is illness the only concern: Each year millions of Americans are injured, and tens of thousands killed, by accidents in and around their homes that may be linked to housing conditions. Access to safe and affordable housing is not just an economic issue, but a major public health issue.

However, much of the public housing in the United States is in disrepair – unhealthy, unsafe, even uninhabitable. The federal Department of Housing and Urban Development (HUD) has been working for many years to fix the problem, but with the cost of bringing public housing up to standard estimated at more than $20 billion nationwide, it’s a daunting task. (It doesn’t help that HUD’s budget, especially the portion for maintenance and renovation, which was inadequate in the first place, has been repeatedly slashed for the last 30 years.)

In 2011, Congress passed the Rental Assistance Demonstration Project (RAD), a pilot program providing for the purchase and renovation of some 60,000 units of public housing by nonprofit organizations or private entities. A linchpin of the program is the requirement that for 15 to 20 years the new owners must continue to make the housing available to the same populations that currently live there.

Public housing has received increasing attention from the field of Health Impact Assessment, which evaluates multiple health impacts of proposed policies and projects. HIAs have been conducted on housing inspections in Ohio and in Marin County, Calif., and on the HOPE VI program in San Francisco. Currently the Health Impact Project is in the midst of an HIA done in collaboration with HUD about changing the rules for elderly and disabled public housing.  In 2011, Human Impact Partners released an HIA of the RAD proposal.

Recently San Francisco, where soaring rents are forcing increasing numbers of low- and medium-income renters out of the city, was awarded a grant from HUD to rehabilitate its public housing stock – enough to renovate three-fourths of all units. In order to qualify for renovation, the units must be sold to private or nonprofit owners who get tax credits. The units then become Section 8 voucher properties (where low-income tenants pay 30 percent of their rent and vouchers make up the difference to the landlord), and the owners sign a contract to keep them as such for 20 years.

Human Impact Partners’ HIA of the RAD project predicted that the program would lead to improved housing quality, decreased stress among residents and decreased crime around renovated housing. But the devil is in the details. We also predicted that RAD, if not done well, could lead to poor health due to potential evictions, displacement, lack of authentic resident inclusion in decision-making, and stress from not knowing whether one’s housing is secure over the long term.

Here’s what we believe San Francisco must do to avoid those potential negative impacts:

  • Ensure that clear standards are set for protecting residents from evictions, displacement and changes in affordability.
  • Require new management to have a long-term plan to preserve the housing stock.
  • Create funding for services, support and protections for those typically hard to house, such as the elderly, large families, people with disabilities, those who have been arrested or incarcerated, and those with poor credit histories.
  • Create an oversight committee of leaders of resident organizations in the housing sites, housing advocates and elected officials.
  • Develop metrics that truly measure determinants of health to understand how RAD affects health over time.

Affordable housing is not only vital for low-income populations, but to the community at large. We’ve seen what happened when the mental health system that helped those who could not live without support was dismantled. Homelessness and incarceration shot through the roof. We don’t want that to happen if public housing goes away. The bottom line: We just aren’t sure that the RAD program offers enough protection to ensure that private interests wouldn’t eventually win out over the public good.

Think about it: You’re a developer who can afford to buy hundreds of units of public housing, get tax breaks from the government for improving them.  All you have to do is agree that for 15 to 20 years you will keep them available for low-income populations.  After that, you must consider keeping them available, but you’re free to sell them at market rates. In markets such as San Francisco, where even modest units have no shortage of takers eager to rent or buy at prices unthinkable until recently, would you think about public health, or your own opportunity to profit?

Policymakers must consider ways to require or incentivize the continued availability of affordable units. Policymakers who want to consider health and quality of life for their most vulnerable residents must assure that safe, well-maintained housing continues to be available for low-income residents.