This paper is the theoretical framework my work is built around. It is one of the most profound and compelling documents I've read in a long time. I hope many will read it and together we will demand a new way!
Implementing the New “Germ” Theory for the Public’s Health: A
Call to Action by Andrea K. Blanch, Ph.D and David L. Shern, Ph.D. published November 5, 2011. The Substance Abuse and Mental
Health Services Administration provided support for the development and
revision of this document.
PREFACE
We believe that America is facing a public health crisis of major
proportions. The health of our citizens,
our economic productivity, the stability of our institutions, and our global
leadership are all being undermined by social conditions creating toxic levels
of stress, which in turn interact with biological vulnerabilities to affect
both individuals and communities.
Our failure to address these social conditions or to help people and
communities become more resilient is primarily a failure of political
will. The scientific basis for
understanding the “epidemics” of today is largely established. We already know how to develop and implement
effective prevention and intervention technologies that could help to remedy
the current situation. What we lack is sufficient public awareness that
solutions exist and sufficient public outrage to demand a comprehensive
national and local response.
In this paper, we review troubling health and social indicators that
should be cause for widespread concern.
We look at epidemiological and neurobiological research on the
connection between toxic stress and a wide range of health and social problems,
and we consider the role of risk and protective factors in building
resilience. We review evidence that
effective intervention technologies exist, present a framework for a public
health approach to treatment and prevention, and outline a political action
strategy.
Throughout the paper, we frame the current public health crisis using
the metaphor of the “germ theory” and the public hygiene movement in the late
19th and early 20th centuries. We are not implying that there is a single
“germ” causing all our social ills just as there was no single germ causing
infectious illnesses. Rather, we want
people to recognize that a public health approach is essential in addressing
these issues. The public health
crusaders who identified the underlying causes of the contagious epidemics of
the 19th century changed our understanding of these diseases and
instigated a radical shift in our collective response to health crises. They developed community infrastructure in
the forms of water and sewer systems, passed vaccination laws, promoted decent
housing and safe food standards, developed community education programs, and
advocated for the availability of antibiotic treatments. Together, these efforts largely eliminated
the threat of infectious disease in developed nations. Focusing on the underlying causes of today’s social
and behavioral health problems and developing the infrastructure to address
them has the potential to inspire a similar revolution.
Public health revolutions often begin when careful scientific
observations in the lab and in the field overturn current assumptions about the
causes of a disease or condition. The
germ theory replaced the prevailing belief that diseases were caused by
“miasmas,” odors associated with poor sanitation that were thought to be
disease-producing. A few decades later,
the germ theory had become so well established that public health crusaders had
enormous difficulty convincing the medical establishment that pellagra was
caused by a dietary deficiency. In this
paper, we use the germ theory metaphor to suggest that our response to the
social and behavioral health epidemics of today has not caught up with our
understanding of their causes.
In public health, theories and interventions rarely replace old ones
suddenly or completely. Rather, they
evolve slowly, and build on constantly changing knowledge and beliefs. By the time the germ theory was established,
“sanitarians” had already made significant progress in cleaning up filthy
neighborhoods and building new infrastructure.
In the early 20th century, progress towards controlling
pellagra through dietary supplements preceded identification of the specific
nutritional component involved.
Interventions to improve the public’s health in the 19th and 20th
centuries did not wait for the final page of the scientific story to be written.
Rather, laws were passed, efforts to contain and prevent illness were
implemented, and new public hygiene measures provided testing grounds for further
scientific observations. We believe that
in a similar manner, we are poised today to make significant “social infrastructure”
improvements that could improve our public health. Further refinements will
emerge as our knowledge base grows.
Effective public health work rests on a clear understanding of the
connections among politics, economics, culture and disease. In this paper, we examine some of the
political battles that were fought in the public health revolution ushered in
by the germ theory, and we speculate about how similar barriers may arise as
society moves to address the epidemics of today. While a complete public health analysis lies
well beyond the scope of this paper – and the expertise of its authors – we
hope that this paper will play a role in stimulating such a discussion.
There are limitations to the germ theory metaphor. It may oversimplify a very complex set of
issues, leading people to look for a “silver bullet.” It may focus our attention too much on
biology, confound infectious and chronic disease models, or underplay the
importance of local variability. Nonetheless, we think this metaphor is useful
because it looks to the strength of current science and the public health
interventions necessary to reap its benefits.
It focuses on biological and environmental factors that we can address
much as we addressed the problems of clean water and safe food. It gets
people’s attention, tells a compelling story, and most importantly, points out
that change is possible.
Our hope is that this paper will inspire people to move into action –
in whatever way they can. We need a large-scale, national public movement to
demand political action to address these issues, and we need it now.
Andrea Blanch, Ph.D.
David Shern, Ph.D.
SECTION
I. THE PUBLIC HEALTH REVOLUTION
In the mid 1800’s, approximately 100,000 people died in the United
Kingdom as a result of a cholera epidemic.
The industrial revolution had led to increased urbanization, and in
1842, the average life expectancy for male industrial workers was fifteen.[1] Death rates in urban centers were twice as
high as those in rural settings. Clearly
the effects of early urbanization and industrialization were devastating to
health.
While many suspected that these horrible public health outcomes were
related to sanitation, no compelling scientific model was available to explain
how poor sanitation caused illness. In
1854, in the midst of a cholera epidemic, John Snow suspected that water was
somehow involved. The story is now
apocryphal: Following a careful epidemiological study of the distribution of
cholera cases, Snow concluded that the water supply on Broad Street was
involved in the infections. He removed the handle from the water pump and the
outbreak ended.[2] Despite this dramatic outcome, Snow’s theory
remained unproven for thirty years, until Louis Pasteur developed the germ
theory of disease and Robert Koch identified the cholera bacillus as the
infectious agent. Koch’s discovery -
coupled with Snow’s practical findings and Pasteur’s general theory - changed
everything. Public hygiene measures were
adopted to reduce exposure, and new techniques like vaccination and antibiotic
treatments helped to control infection.
With the emergence of effective public health technologies, demand for
public hygiene measures had new force.
Legislation was passed, standards were set, and new infrastructure was
constructed to deliver clean water and safe food and to dispose of waste
effectively. Over time, basic hygiene
practices such as hand washing and sanitizing instruments became routine in
medical care and in daily life. These
public health measures resulted in the greatest reduction in disease and
mortality in history. Today, citizens of
developed nations take this public health infrastructure for granted, and
public health measures are among the first goals adopted in developing
countries. Yet for most people, public
health infrastructure is invisible.
Today we have an epidemic of behavioral health disorders in the United
States. The United States has the highest
rates of mental illnesses in the world, according to World Health Organization
(WHO) international epidemiological surveys.[3] On many measures of our competitiveness and
human capital we are progressively lagging behind other developed nations. We’ve dropped from 11th to 42nd
in the world in longevity during the last twenty years.[4] Clearly something is terribly wrong with our
health.
Behavioral health disorders are not only the most disabling of all
illnesses in the United States and throughout most of the world [5], they are often the
progenitors of other general health problems (e.g., inactivity and obesity,
smoking and lung cancer, risky sexual behavior and HIV). While we struggle with
these problems and attempt to implement various ‘reform’ efforts, no general
theory of the etiology of behavioral health problems is yet widely
accepted. Such a theory could guide a
systemic approach to prevention and intervention.
We think that the data to support such a theory are largely
developed. The theory involves the
interaction of genetic vulnerability with toxic environmental stress to produce
neural, endocrine and immune system changes that become the hallmarks of both
behavioral health disorders and a range of general health conditions that are undermining
our health and well being. In the past
three decades, we have learned much about how genetic factors contribute to
health and illness and how chronic and toxic stressors contribute directly to
behavioral health, health and social outcomes.
We have learned about the protective factors that help people to
overcome potentially damaging circumstances and how effective social policies
and programs can reduce the likelihood of trauma. Much is now known about how to prevent
several of the agents that cause individuals to become ill. These are the modern day ‘germs’ of
behavioral health problems. Rigorous,
long-term research now documents our ability to combat these agents and
dramatically improve behavioral and general health. We are on the verge of the next great leap
forward in public health.
In this paper we will sketch the features of this new general theory
of health and illness. We will also
outline a public health response to the current epidemic of behavioral health
and social disorders. This is a call to
action to mobilize the political will to demand that these public health
interventions be universally available.
The time to act is now. We have
no time to waste.
SECTION II.
THE EPIDEMICS OF TODAY
While infectious diseases have largely been brought under control in
developed nations, it is clear that there are serious problems with our public
health. Not only has life expectancy in
the United States plummeted in comparison with other countries, so have a
number of other health indicators. The
U.S. infant mortality rate is higher than in most developed countries, and the
gap is widening – the U.S. ranking fell from 12th in 1960 to 29th
in 2004.[6] The U.S. also ranks very low (24th)
in comparison with other developed countries on “disability-adjusted life
expectancy” – the number of healthy years that can be expected on average in a
given population.[7] Even more striking, there is huge
variability in health status within the United States, and the single strongest
predictor is income. Children living in poverty are seven times more likely to
have poor health, compared with children living in high-income households.[8] There is a 14.7 year difference in life
expectancy between the longest- and shortest-lived counties in the United States,
and that gap has widened by 60% in the past twenty years.[9]
The U.S. also leads the world in lifetime prevalence rates of
behavioral health disorders. In a study
of 17 countries in Africa, Asia, the Americas, Europe and the Middle East, WHO
found that the U.S. had the highest prevalence rate of “any disorder” (47.4%),
anxiety disorders (31%), mood disorders (21.4%), and impulse control disorders
(25%). In the category of substance
abuse disorders, the U.S. ranked second, with a lifetime prevalence rate of
14.6%, surpassed only by the Ukraine, with a rate of 15%.[10]
Many of our current health problems appear to be related to chronic
conditions such as obesity, heart disease and diabetes. In a study of 27 countries where health
examinations are routine, the U.S. has the highest rate of obesity
(30.4%). Mexico is second with a rate of
24.2%; Japan and South Korea have the lowest rates (both at 3.2%).[11] In a comparison with five other nations
(Australia, Canada, Germany, New Zealand, and the United Kingdom) the United
States ranked last on a measure of “healthy lives,” scoring poorly on all three
indicators (mortality amenable to healthcare, infant mortality, and healthy
life expectancy at age 60).[12]
Our society appears to be “sick” in other ways, as well. International crime rate comparisons are
notoriously difficult to make due to differences in reporting, but firearm-related
deaths and homicide among young males appear to be significantly higher in the
U.S. than in other economically comparable countries. In one study, the rate of firearm-related
deaths in the U.S. was eight times that of our economic counterparts.[13] In another study, the U.S. homicide rate for
males 15-24 years old was the highest of 22 developed countries, more than four
times the rate of the next highest country, Scotland.[14] We incarcerate people at a rate that is far
higher than any other nation – 700/100,000 population compared to 110 for
China, 80 for France, and 45 for Saudi Arabia. With a prison population of 2.3
million, we now have more people incarcerated than any other nation. In a study of relative poverty rates in 21
rich countries, the U.S. had the second highest poverty rate both overall and
for children, surpassed only by Mexico.[15] Research also suggests that mobility in and
out of poverty is lower in the U.S. than in almost every other rich
country. We currently have 46 million
people living in poverty[16], over a half
million individuals are homeless on any given night[17], over 50 million
people and half of all children using food stamps[18], almost 18% of
children living below the poverty line, and at least 15 million people living
in poverty despite having a job.[19] America also has
the greatest inequality of income and wealth in the industrialized world.[20]
Our children’s educational performance is
suffering. In 2007, U.S. students ranked 21st in science literacy[21], 24th
in problem-solving literacy[22], and 25th
in mathematics literacy[23] compared to the 30
OECD (Organization for Economic Co-Operation and Development) countries. Our educational status in comparison with the
rest of the world is also decreasing: the U.S. ranking of postsecondary
graduation rates fell from second in 1995 to 16th in 2005. [24]
The health and social status of our workforce has profound effects on
economic productivity and international competitiveness. Measured by time spent
on the job, Americans are the most productive workers in the world – we now
work an average of 200 hours per year more than workers in the other OECD
countries, even more than the Japanese.
Despite our long hours, the first decade of the 21st century
was economically disastrous. Buchanan
reports that, according to the International Monetary Fund, U.S. gross domestic
product (GDP) as a percentage of world GDP dropped from 32% to 24% between
2,000 and 2010. No nation in modern
history, save for the former Soviet Union, has seen so precipitous a decline in
relative power in a single decade.[25]
SECTION
III. IS THERE A COMMON DENOMINATOR? THE EPIDEMIOLOGY
Is it possible that these broad health, social and economic changes in
the U.S. are related in some way? It has
long been accepted that social determinants affect the health and productivity
of the population.[26] Social determinants are characteristics of the
built or social-psychological environment that are productive of chronic stress
and trauma and are clearly associated with diminished health status and
academic and occupational achievement.
We will argue that the effects of these social determinants are mediated
through individuals’ reactions to the toxic stress associated with living in
unpredictable environments, which in turn, can lead to neurological, hormonal,
endocrine and immune system changes that underlie the development of behavioral
and general health conditions. The
development of these conditions compromises academic and, ultimately,
occupational achievement. The
deterioration of human capital, therefore, underlies the troublesome health and
social indicators summarized earlier. Individual differences in vulnerability
conferred either through heredity or skills training may interact with toxic
stress or other environmental variables in determining an individual’s response
and the ultimate course of his/her development through life. We further argue that, based on this
understanding of the effects of toxic stress, we have multiple interventions
that can be used to either reduce the presence of risk factors and/or to
strengthen individual of community resilience for weathering these effects.
Many of the social determinants discussed above are directly related
to poverty. Public health is built on
the recognition of epidemiological connections between poverty, the broader
social and economic patterns causing it, and particular diseases.[27] The relationship between poverty and health,
often referred to as the social gradient in health, is well established. In general, the wealthier you are, the
healthier you will be and the longer you will live.[28] However, this relationship is mediated by
numerous factors, and it is these factors that public health reformers seek to
uncover. For example, although in the 18th
and 19th centuries infectious diseases were associated with the
poor, they were not confined to poor neighborhoods. Elaboration of the germ theory led to the identification
of conditions associated with poverty that increased the likelihood of exposure
to pathogens, and turned many public health scientists into advocates for
change. Rudolph Virchow, for example,
was sent to investigate an outbreak of cholera in Upper Silesia and quickly
became a crusader for better employment and living conditions.[29] Similarly, although pellagra was so highly
associated with poverty that Goldberger stated: “The problem of pellagra is in
the main a problem of poverty,” it was a specific diet associated with poverty
– a diet particularly common among poor sharecroppers and mill workers in the
rural south – that led to the condition.
The behavioral health epidemics of today are no more “caused by” poverty
than yellow fever, cholera, or pellagra were, but poverty clearly puts people
at risk. The theory proposed in this
paper suggests that it is high levels of toxic stress – often associated with
but certainly not limited to the poor -- that mediate the relationship between
poverty and behavioral health and social problems.
If toxic stress is the mediating factor between social conditions and
poor health outcomes, we would expect toxic stress to have an impact regardless
of income. In fact, an extensive
epidemiological study convincingly demonstrates a strong relationship between
the toxic stress of childhood trauma and poor behavioral and general health
outcomes in a middle class population. The Adverse Childhood Experiences (ACE)
Study[30] is a retrospective
and prospective analysis of the relationship between traumatic stress in
childhood and the leading causes of morbidity, mortality and disability in the
United States, including chronic medical diseases, mental illness, obesity, and
substance abuse. A collaborative effort
between Kaiser Permanente’s Department of Preventive Medicine in San Diego and
the Centers for Disease Control (CDC), the study includes over 17,000
individuals. Subjects are middle-class
Americans with health insurance: Eighty
percent are white (including Hispanic), 10% black, and 10% Asian; half are men
and half women; 74% have attended college; their average age at entry into the
study was 57.
Subjects were asked whether or not they had experienced any of eight
ACE categories in the first wave of the study; two categories of neglect were
added in the second wave. The ACE
categories are shown in the following chart,[31] along with their
overall prevalence rates:
ACE Category
|
Definition
|
Prevalence
|
Emotional abuse
|
Recurrent threats, humiliation
|
11%
|
Physical abuse
|
Beating, not spanking
|
28%
|
Sexual abuse
|
Contact abuse only
|
22%
|
Domestic violence
|
Mother treated violently
|
13%
|
Substance abuse
|
Alcoholic or drug user in household
|
27%
|
Incarceration
|
Household member imprisoned
|
6%
|
Mental illness
|
Household member chronically depressed, suicidal, mentally ill or in
psychiatric hospital
|
17%
|
Parental separation
|
Not raised by both biological parents
|
23%
|
Physical neglect
|
Lack of adequate food, shelter, physical support
|
10%
|
Emotional neglect
|
Family failed to provide a source of strength, emotional support,
and protection
|
15%
|
The individual’s ACE score is calculated by a count of the number of
categories that had occurred during their first 18 years of life. Multiple occurrences are not recorded, making
this a conservative measure. ACE scores
are then matched with the individual’s
current state of health and well-being and with various measures of health care
utilization, cost, and death.
Only one-third of the population has an ACE score of zero. One in six has an ACE score of 4 or more; one
in nine has a score of five or more.
Women are 50% more likely than men to have an ACE score of five or
more. ACEs do not occur randomly: If any one category is present, there is 87%
likelihood that at least one additional category will be present. ACE categories are approximately equal in
their impact.
There are strongly proportionate and significant relationships between
ACE scores and a variety of mental health, health, behavioral and healthcare
utilization measures, decades after the experience of adverse childhood
events. Mental health indicators such as
chronic depression, hallucinations, suicide attempts, and use of psychotropic
medications are all strongly and significantly related to ACE scores, as are
health risk behaviors such as smoking, alcohol use, IV drug use, and multiple
sex partners. IV drug use is
particularly striking - a male child with an ACE score of 6 or higher is 46
times more likely to be an injection drug user than a child with a score of
0. Very strong relationships are also
reported between ACE scores and a host of biomedical conditions, including
liver disease, autoimmune disease, chronic obstructive pulmonary disease and
coronary artery disease – even after controlling for conventional risk factors
such as smoking. Healthcare
utilization, costs, and life expectancy are also strongly related to ACE
scores. After 14 years of prospective
research, the study finds that people with an ACE score of 6 or higher die
almost 20 years earlier than those with an ACE score of 0, even with otherwise
similar characteristics.
Traumatic Event
|
Lifetime Prevalence of Trauma
|
Men
(n=2,812)
|
Women (n=3,065)
|
%
|
%
|
Rape
|
0.7
|
9.2
|
Molestation
|
2.8
|
12.3
|
Physical attack
|
11.1
|
6.9
|
Combat
|
6.4
|
0.0
|
Shock
|
11.4
|
12.4
|
Threat w/ weapon
|
19.0
|
6.8
|
Accident
|
25.0
|
13.8
|
Natural disaster
|
18.9
|
15.2
|
Witness
|
35.6
|
14.5
|
Neglect
|
2.1
|
3.4
|
Physical abuse
|
3.2
|
4.8
|
Other trauma
|
2.2
|
2.7
|
Any trauma
|
60.7
|
51.2
|
Note: Adapted from Kessler et al (1995).
|
The ACE study focuses on adverse events that occur before the age of
18, and there is substantial evidence that abuse occurring early in life has
more profound impacts than trauma during adulthood. Young children lack a stable sense of self
that can help moderate the impact of extreme events, and toxic stress has a
direct impact on biological and neurological development.[32] However, acute and chronic stress in
adulthood can also have profound consequences.
As the chart at the left shows, over 60% of men and 50% of women
experience significant trauma at some point in their lifetime.[33]
Lifetime experience of acute and chronic stressors has a direct impact
on service utilization. According to
most estimates, trauma is an almost universal
experience among people who use public mental health, substance abuse and
social services, as well as people who are justice-involved or homeless.[34] While rates of
trauma vary depending on specific definitions and research design, it is
estimated that as many as 90 % of people in psychiatric hospitals and 92 - 97%
of homeless women have histories of physical or sexual abuse. Between 75 and 93 percent of youth entering
the juvenile justice system have experienced some degree of trauma, and among
males who experienced maltreatment prior to 12 years of age, 50-79 percent
became involved in serious juvenile delinquency.[35] One study showed that men who have witnessed their parents'
domestic violence are three times more likely to abuse their own wives than
children of non-violent parents, with the sons of the most violent parents
being even more likely to abuse their wives.[36]
Children who are exposed to violence often grow up to engage in or
become victims of crime – a large percentage of both men and women in the
criminal justice system have experienced trauma in childhood. Eighty percent of
women in jails and prisons have been victims of sexual and physical abuse,[37] and in one study,
all sixteen men sentenced to the death penalty in California had histories of
family violence, including thirteen cases of severe physical and/or sexual
abuse while in foster care.[38]
The medical and social costs of trauma and chronic stress are
staggering. The cost of chronic illness goes far beyond the actual medical
expenses. The direct cost of chronic
illnesses in 2006 comprised 84% of overall health expenditures or well over 1.5
trillion dollars [39] Total cost to the
economy of chronic illnesses is likely 4 times higher than the direct medical
expense.[40] Although the full cost of violence and abuse
to the health care system has not yet been estimated, a study using 2008 health
care and population data show that the predicted incremental cost to health
care system ranges between 17% and 37.5% of total health care expenditures.[41]
The epidemiological data reported in the ACE study suggest that there are
two basic pathways through which the toxic stress of adverse childhood events
affect public health. First, they
increase conventional risk factors such as smoking, drinking, eating and
engaging in risky sex. Second, chronic
stress affects the developing brain and body and causes dysregulation of the
stress response. Biomedical, behavioral
and neuroscience research is now confirming this theory.
SECTION IV.
THE IMPACT OF STRESS: NEUROBIOLOGY AND CAUSAL PATHWAYS
While John Snow’s work on the Broad Street
water pump was a dramatic event, the development of a systematic public health
response to contagion required elaboration of the ‘germ theory’. In the thirty years following his
epidemiological studies, infectious agents were isolated and identified, modes
of transmission were detailed, methods for blocking the infectious agents were
developed and tested – including both treatment and prevention -- and anomalies
in the theory were identified, studied and finally understood. As knowledge accumulated, replicable
technologies for intervention were developed.
As these elements fell into place, the modern system of public health
emerged. The prevention and treatment of infectious diseases had a profound
impact on the overall health of industrialized nations.
Our understanding of the antecedents of
the behavioral health epidemic described earlier is much more refined than
Snow’s knowledge of bacteriology when he removed the pump handle. We have animal and human data that elaborate
the relationships between genetic predisposition and environmental stressors in
the development of illness. We have impressive data regarding the effectiveness
of interventions to reduce or ameliorate the effects of risk factors. We have technologies informed by our
knowledge of chronic stress and trauma that improve public health by reducing
the level of stress and stimulating the development of resilience in
individuals and communities. All of the
knowledge for an effective, systematic public health response to the behavioral
health epidemic is available. What we lack is general acknowledgement of this
theory and a concrete plan of action to implement the next great wave in public
health in communities across the nation.
Genetic
Predisposition and Stress as Infectious Agents.
While once
extremely controversial, it is now nearly universally acknowledged that mental
illnesses and substance use disorders have an important genetic component.
Generally consistent with the scientific literature, heritability estimates for
mental illnesses from one large twin study ranged from 0.16 for phobia to 0.66
for drug abuse or dependence.[42] This means that from 16% to 66% of the
differences between people in expression of illness can be attributed to
genetics. Estimates for the heritability
of schizophrenia are higher, approximately 0.80, indicating significant effects
of genetics or genetically correlated effects.[43] However, the relationship between genetic
risk and ultimate expression of an illness is not simple. As with most health conditions, genetic
vulnerability and life experiences combine to produce the signs and symptoms of
mental and addictive disorders.
Addiction is probably the clearest example. As noted above, estimates of the heritability
for drug abuse and dependence are relatively high – indicating an important
genetic component for this disorder. If
an individual never has contact with drugs, however, he or she will not become
addicted. Similarly, we know from twin
research that identical twins are concordant for schizophrenia more often than
fraternal twins, indicating a substantial genetic component. However, the fact that identical twins are
not always concordant for schizophrenia shows that causal factors other than
genetics are also at work. Understanding
environmental influences in the context of an individual’s genetic risk profile
is therefore essential.
In combination with genetic vulnerability,
we’ve come to understand that toxic stress is associated with the development
of a wide range of disorders from mental illnesses to cardiac disease.[44] We now know from both animal and human
research that chronic stress and trauma are associated with structural changes
to the hippocampus, amygdala and pre-frontal cortex of the brain. Events that occur early in life have long-term
effects on emotionality and stress responsiveness that can affect how people
react to environmental challenges, predispose them to high risk behaviors, and
increase the rate at which the brain and the body age.
Allostasis is the process of maintaining
equilibrium in the face of threat. It
involves the production of hormones (adrenal steroids) that provoke the flight
or fight response. While clearly
adaptive in the short term, prolonged exposure to these hormones is associated
with neural and endocrine damage that can ultimately result in cognitive
impairment, illness and death. Early
experiences in life may prime the system to be overly responsive to
environmental stress. Animal studies
indicate that both pre- and post-natal stressors can have life-long impacts on
the brain, causing hyper-reactivity, leading to prolonged exposure to cortisol
and cytokines that damage neural structures, and ultimately affecting multiple
areas of mental and general health as well as social functioning.[45] The brain, as the master controller of motor,
affective, immunological and endocrine effects, likely encodes this damage and
orchestrates its long-term effects
Trauma in adulthood also directly affects
the brain. In neuroimaging studies, subjects
with post traumatic stress disorder (PTSD) who are exposed to stimuli that
remind them of earlier traumatic events show increased cerebral blood flow in
the right medial orbitofrontal cortex, insula, amygdala, and anterior temporal
pole, and a relative deactivation in the left anterior prefrontal cortex,
specifically in Broca’s area, the expressive speech center in the brain. In short, reminders of trauma activate areas
of the brain that support intense emotions and decrease activity of brain
structures involved in inhibiting emotions and translating experience into
communicable language.[46] These findings have important implications
for treatment.
Finally, although still ambiguous, data
are becoming available that demonstrate the interaction of specific genes and
environmental stress. Several
investigators have demonstrated that individuals with a particular genotype
respond differently to stress than individuals with an alternative gene
composition. While replication of these
studies is proving difficult, the combination of this genotype and stress seems
to be associated with increased depressive symptoms.[47] Other research demonstrates that individuals
with specific genetic fingerprints who are exposed to natural disaster and
additional environmental stressors (unemployment and crime rates) are more
likely to develop PTSD[48] than persons
living in areas with less social disruption.
Genetic expression itself is environmentally mediated. Epigenetics, an emerging subfield of
genetics, refers to inherited changes in genetic expression that occur in
response to environmental influences.
Epigenetic research identifies issues in the expression of genes or in
the replication of genetic material that seem to be associated with the
development of mental illnesses. While
much remains to be learned about the specific interaction of genes and
environments in promoting health or predisposing illness, this early work is a
step towards understanding how social events interact with genetic
vulnerability and are differentially reflected in neuronal structures that may
even be inherited across generations.
Resilience and Recovery from
the Impact of Stress. If stress is a causal factor in behavioral
health disorders, why doesn’t everyone
who is exposed to chronic and toxic stress exhibit symptoms of distress? In fact, people respond to potentially
disturbing events in very different ways, and their responses can vary
significantly over time and depending on context. While part of the answer to
this question lies in differential genetic vulnerability, there is also
evidence that environmental factors contribute to individual resilience and
recovery.
Resilience refers to the capacity of individuals to
maintain a relatively stable equilibrium and healthy levels of psychological
and physical functioning after exposure to a potentially disruptive event.[49] Resilience has been demonstrated in both
adults and children, and it appears to be common, at least after isolated
traumatic events. Meta-analyses demonstrate that on average, only 20% of adults
who experience severe traumatic stressors develop PTSD.[50] The percentage of individuals who develop
other behavioral health problems depends on previous and subsequent traumatic
events as well as other personal and contextual factors.
Many individuals who display
severe reactions to acute or chronic stressors, either immediately or after a
delay, recover to pre-trauma levels of functioning over time.[51] The recovery
process has been extensively studied since Judith Herman observed that many
people move through stages of safety, remembrance and reconnection as they
heal.[52] A number of variables that affect recovery
have also been identified. For example,
trauma that is intentionally inflicted, especially by a trusted friend or relative,
is often more profoundly disturbing than unintentional trauma, such as that
caused by a natural disaster.[53] Recovery is most often studied in the context
of professional helping interventions, but there is growing evidence that
recovery, like resilience, is a natural biological process.[54]
Resilience and recovery have profound implications for how we as a
society respond to toxic stress.
Preventive and health promotion activities can produce resilient
individuals who are better able to accommodate stress. Treatment is clearly an essential component
of an overall response when appropriately timed to support natural
growth-related processes.[55] How can we maximize resilience and
self-healing while also responding effectively to those most severely affected?
Understanding risk and protective factors can help. In a review of 68
studies of PTSD, several risk factors were consistently found to increase the
likelihood of developing PTSD, including: a previous traumatic event, previous
psychological problems, family history of psychological problems, extent to
which the traumatic event was life threatening, amount of perceived support
after the event, emotional response at the time of the event, and dissociation
at the time of the event. Dissociation, which is the experienced disconnection
between thoughts, feelings and actions, was the strongest predictor of
developing PTSD while prior history of personal or family psychological
problems and previous trauma had the weakest association.[56]
Protective factors – those
associated with resilience and recovery – include the ability to cope with
stress in a healthy manner, having good problem-solving skills, seeking help,
believing that you are in control of your feelings, finding a support group,
connections with family and friends, self-disclosure of trauma, feeling good
about one’s own actions in the face of danger, spirituality, identifying as a
survivor rather than a victim, helping others, finding positive meaning in the
trauma, and being able to respond effectively despite feeling fear.[57] [58]
SECTION V.
EFFECTIVE TECHNOLOGIES TO CONTAIN THE EXPRESSION OF BEHAVIORAL HEALTH
PROBLEMS
Just as the movement to improve sanitation
preceded acceptance of the germ theory, we have compelling reasons to implement
our existing technology even though all of the mediating mechanisms in the
development of mental health and substance use conditions are not fully
understood. During the public hygiene revolution interventions were developed
to:
·
reduce
community risk factors (e.g., draining
swamps, building sewage systems, setting standards for safe food and
water);
·
strengthen
community protective factors (e.g., building decent housing to reduce
overcrowding, paving streets, improving wages, supplementing traditional
diets);
·
decrease
individual exposure to pathogens (e.g., quarantines, improved medical practices including use of antiseptics,
changing personal hygiene and sanitary practices);
·
increase
the capacity of individuals to resist infection (e.g., vaccinations); and
·
contain
infection through effective treatments (e.g., antibiotics).
With regard to the current epidemic of
behavioral disorders, we have a considerable body of knowledge about
interventions that work. Investment in a
public health approach would likely result in the development and testing of
additional tools and approaches.
Reducing
Community Risk Factors. While
the evidence base is limited, some effective strategies for reducing major
sources of toxic stress have been identified.
For example, WHO cites several programs that are effective in reducing
the incidence of child maltreatment, and several others that are promising.[59] Effective programs focus on improving
parenting skills and supports in populations with established risk factors for
child maltreatment, including the failure of infant-parent bonding, unrealistic
expectations about child development, a belief in the effectiveness of harsh
physical punishment and an inability to provide quality child care when the
parent is absent.
The most widely applied and evaluated
child abuse prevention model is home visitation. A recent review of outcome studies showed
that home visitation programs, on the average, reduced child maltreatment by
parents and other family members by 40%.[60] The most successful
programs focus on families in greater need of services, begin during pregnancy
and continue until at least the second year of the child’s life, are flexible
in implementation, actively promote positive care giving behaviors, cover a
broad range of issues specific to the family, include measures to reduce stress
within the family and use nurses or trained semi-professionals.
Parenting education programs focus on the
parents of children aged 3-12 years, use active teaching techniques, and
promote positive reinforcement, non-violent discipline methods and negotiating
and problem-solving strategies. They have been shown to be effective, although
most evaluations have examined the impact on proximal outcomes such as parental
competence and parent-child conflict rather than rates of maltreatment. However, In contrast, a recent clinical trial of the Positive
Parenting Program demonstrated a 28% reduction in substantiated child
maltreatment, a 19% reduction in out of home placements and a 20% reduction in hospital
and emergency room admissions for child maltreatment injuries.[61] These large differences were observed at the
county level for experimental versus control counties using countywide
interventions rather than those targeted at high risk families.
Other primary prevention efforts have been
shown to be effective in reducing exposure to a variety of toxic
stressors. In a systematic review of
prevention programs meeting rigorous methodological standards, WHO concluded
that school-based programs to prevent child sexual abuse are effective in
strengthening protective factors against this type of abuse, although the
impact on rates of abuse was unclear.[62] A systematic review and meta-analysis of 44
anti-bullying programs showed that overall, school-based anti-bullying programs
are effective: on average, bullying decreased by 20-23% and victimization
decreased by 17-20%.[63] Comprehensive smoking prevention programs
have been widely successful in reducing exposure to tobacco.[64] These findings show that reducing the rate of
exposure to chronic and toxic stressors is possible.
Increasing
Community Resilience and Resistance to “Disease.” Public policies and programs that
encourage connection to the community and that express norms that favor
pro-social behavior help to provide the environments that promote health and
wellbeing. Examples include[65]
• Participation
in church or other community group,
• Strong
cultural identity and ethnic pride,
• Access
to support services, and
• Community
cultural norms against violence.
Community wide initiatives can help
stimulate and strengthen communities, increasing their resilience to toxic
influences. Tax policies[66], community
coalitions[67], community
university partnerships[68] and anti-violence
initiatives[69] have all been shown
to enhance community health and wellbeing.
Grassroots efforts to develop resilient and sustainable approaches to
the environment and the economy are emerging across the country and the globe,[70] and psychological
and emotional resilience is an essential component.
Decreasing
Individual Exposure to “Pathogens” (Toxic Stress).
Once we understand the pathogenic effects of toxic stress, we have
pragmatic as well as moral rationale to prevent exposure whenever
possible. Programs that seek to remove
or protect children or women from abuse or domestic violence, that provide
community alternatives to jail or juvenile justice facilities, or that seek to
minimize disruption in the lives of children in foster care are all designed to
reduce individual exposure to trauma and toxic stress. Policies regarding the use of restraints in
psychiatric treatment facilities seek to reduce the rates of re-traumatization
experienced by persons in mental health crisis.
Limiting the number of times a soldier can be deployed to a war zone or
the total overall exposure of first responders to traumatic circumstances have
similar goals. While the research on the
impact of these programs is just beginning, it is reasonable to hypothesize
that there will be a substantial public health benefit to reducing the overall
exposure to toxic stress.
Increasing
Individual Capacity to Resist “Infection.” Research shows convincingly that technologies exist that successfully
increase resiliency – i.e., that strengthen individuals’ ability to cope with
chronic and toxic stress in healthy ways.
These techniques have been referred to as “behavioral vaccines” in
recognition of the role they can play in preventing today’s epidemics.[71] In 2009 the Institute of Medicine (IOM) released a
synthesis of the research literature on the prevention of mental, emotional and
behavioral disorders in young people.
This report documents a formidable armamentarium of rigorously tested
prevention interventions that have been shown to reduce the prevalence of
socially maladaptive behaviors and promote the development of pro-social,
adaptive behaviors. Importantly, many of
these interventions target young children and their families and are therefore
conceptually aligned with findings regarding the life-long impacts of early
childhood experiences. The IOM conceptualizes preventive interventions in a
life span developmental framework that is explicitly sensitive to developmental
neuroscience. Stress results from
unexpected and/or unmanageable experiences that are unpredictable and, from the
individual’s perspective, uncontrollable. One method used to create greater
control is the development of personal competencies that help to reduce
uncertainty and create environmental mastery.
The sense of mastery that develops from specific behavioral success
experiences, along with a sense of self efficacy and confidence that the
stressful situation will be resolved, increases the individual’s ability to
modulate stressful reactions and reduces hormonal responses to stress.
Perhaps the best known of these
interventions is the Nurse Family
Partnership, in which nurses work with first-time pregnant women prenatally
and for the first two years after birth. Nurses train and support these new
mothers, increasing their competence to rear their infants effectively. The nurse family partnership and other
similar interventions improve the mothers’ caregiving competencies, promote
mother-infant attachment and result in a broad range of beneficial effects on
youth development and long-term health.
Through these interventions, youth develop competencies that help them
to navigate unpredictable environments and better manage their own emotional
responses to stress. Participation in
these programs improves social inclusion, improves bonding and cohesion in
pro-social groups, facilitates healthful development, buffers stress, reduces
the occurrence of maladaptive behaviors and ultimately prevents the emergence
of behavioral disorders.
Long term follow-up data are also
available for the Seattle Social
Development Project.[72] This intervention promotes opportunities for
children’s active participation in the classroom and family, and reinforces
efforts and accomplishments. It involves
teachers and adult caregivers in the intervention and was implemented in grades
1 through 6 with random assignment to classroom. Fifteen-year follow-up data are available for
27 year olds who have not received any systematic interventions since age
12. Data contrasting experimental and
control classrooms show significant effects of the intervention on
socioeconomic status, social engagement, completion of an associate’s degree,
rates of mental health symptoms, diagnosable mental illnesses and lifetime
rates of sexually transmitted diseases.
The Good
Behavior Game is another school-based classroom management technology used
in elementary school. At ages 19 to 21,
males who received the intervention in the first or second grade had
significantly reduced rates of cigarette smoking, fewer alcohol or substance
abuse/dependence disorders and significantly lower rates of antisocial
personality disorder than students in the control classrooms.[73] These long-term outcomes underscore the
value of skill-based interventions decades following their administration. These interventions improve resilience and
adult achievement while helping to prevent the onset of mental and addictive
disorders.
Resiliency training programs for adults
have not been as well studied as those for children and youth. However, it is worth noting that the military
has adopted a comprehensive program for building resilience in soldiers.[74][75] The Army’s “Comprehensive Soldier
Fitness” (CSF) program was developed in part due to increasing rates of suicide
and PTSD among soldiers returning from deployment. The program uses established principles of
positive psychology to help prepare soldiers for sustained operations. The
director of CSF has compared the program to marathon training, where the
likelihood of injuries is reduced by preventative care and training.[76] Contractors that work in areas of conflict or
disaster are adopting similar resilience training programs.[77]
Containing
“Infection” with Effective Treatment. We also have considerable
information about effective treatments for mental and addictive disorders.
Effective treatment is critical not only because it benefits the individuals
involved, but because it can help prevent the transmission of “infection” to
others. Both mental illness and
addiction in the family are considered adverse experiences in the ACE study. Children in households where these disorders
are present are often exposed to unpredictable environments, and are at risk
for multiple stressors. Effective
treatment for family members can prevent or reduce negative impacts on the next
generation.[78]
Effective treatment programs exist for a
wide variety of substance abuse and mental health conditions. A meta-analysis of 78 drug abuse treatment
studies found a statistically significant and clinically meaningful impact of
treatment in reducing drug use and crime. [79] Collaborative care
approaches for treating depression in primary care show significant effects in
improving depression 5 years following the intervention.[80] SAMHSA’s National Register of Evidence-Based
Programs and Practices (NREPP), which lists prevention, promotion and treatment
programs that are scientifically tested and readily disseminated (with at least
one published comparative effectiveness
study), includes 65 listings for substance abuse treatment and 51 listings for mental
health treatment.[81] There is also growing evidence that for
individuals whose mental health and/or addiction problems are related to
violence, addressing trauma directly , and in a way that fully integrates the
trauma counseling with other treatments, is more effective than treatment
without attention to trauma.[82] Looking
specifically at PTSD, a meta-analysis of psychotherapy found that the majority
of patients treated in randomized trials recover or improve, making these
approaches some of the most effective psychosocial treatments devised to date.[83] Although many
patients continued to have residual symptoms, if we were to integrate the
knowledge we now have about the neurological impact of chronic and toxic stress
into our treatment interventions, it is likely that we could further improve
outcomes.
Our understanding of the neurobiological underpinnings of
stress-related conditions opens new possibilities for treatment.[84] We have long recognized that traumatized
individuals respond to reminders of the past by automatically engaging in
behaviors that were appropriate at the time of the trauma, but are no longer
relevant, and that they have trouble with sustained attention and focused
concentration. Many traumatized children
and adults lose the ability to recognize their feelings, internal physical
sensations and muscle activation – a phenomenon called “alexithymia.” The rational, executive verbal part of the
brain – the part engaged by most verbal therapies - has limited ability to
control emotional arousal or change fixed action patterns. Techniques that address awareness of internal
sensations and physical action patterns – such as dialectical behavior therapy
(DBT) – show great promise and deserve further study. Similarly, the lateral
nucleus of the amygdala has been shown to be the critical structure in the
brain in the formation of conditioned fear memories, which when coupled with a
sense of helplessness, can result in chronic mechanistic compliance or resigned
submission. Therapeutic approaches that
move people into action – like improvisational theatre or self-defense classes
– can redirect the flow of information from the central to the basal nucleus of
the amygdala and the motor circuits of the ventral striatum, and have the
potential to help people overcome the habitual passivity that can be a hallmark
of stress-related conditions.[85]
In reality, the categories above are overlapping, and most
interventions combine multiple elements.
For example, the concept of “nurturing environments” has been proposed
as a framework to integrate efforts to minimize toxic conditions; teach,
promote, and reinforce pro-sociality; monitor and limit opportunities for
problem behavior; and promote psychological flexibility.[86]
SECTION VI. A PUBLIC HEALTH INFRASTRUCTURE FOR TREATMENT
AND PREVENTION
Both the science and the practice of public health depend on an
infrastructure for data collection and analysis, field research, local action
(including program implementation), policy change, development and testing of
new tools and public education.
Data and Surveillance. As
early as the 17th century, the colonists recognized that they
couldn’t protect people’s health unless they had hard facts about births, death
and illnesses. Systems to gather vital statistics quickly became an essential
part of public health. [87] Data were used to map of the outbreak of
epidemics – for example, mapping cases of cholera helped John Snow identify the
tainted pump. Likewise, surveillance systems were helpful in monitoring the spread
of infectious diseases, which in turn allowed public health “detectives” to
discern conditions in which a particular disease was likely to thrive.[88] If we are going to make progress with today’s
epidemics, we will need an equal investment in data gathering and
monitoring. For example, mapping
outbreaks of bullying or street violence might help identify local
circumstances that are causing the problem – or at the very least, would guide
the need for intervention.
Unfortunately, much of the data and information that would be useful
in addressing behavioral health epidemics are either not gathered or are not
available for public health purposes.
This is due, in part, to the lack of integration among various health and
human services, and in part to the criminalization of many of the behaviors of
concern. We know, for example, that
children who witness a violent crime and women who are raped are both at
elevated risk for future problems.
However, since these events are tracked by the criminal justice system,
data are not readily available for public health purposes. Similarly, we know that the impact of a
traumatic event ripples through families and communities, but we have no way of
systematically monitoring those impacts.
We need surveillance of the factors that are known to underlie the
development of behavioral health disorders and an integration of these data
into a coherentpublic health strategy to ameliorate the effects of toxic
stressors. As we do so, economies and
individuals should become more resilient to stressful perturbations.
Field Research.
Public health also depends on careful study of local environments. One of the hallmarks of the early public
health movement was the deployment of teams of public health researchers to the
site of new outbreaks, where the interaction of the disease with local
geography, climate and culture could be closely observed. Their job involved administrative duties (enforcing
quarantines and other mandated procedures); detective work (looking for sources
of contamination); and scientific observation (attempting to understand the
spread of the disease and its potential containment). Often, local research led to solutions that
could not have been developed from a distance.
For example, understanding that yellow fever was spread by mosquitoes
led to a national social policy of draining swamps. However, when there was an outbreak of yellow
fever in an arid region of Mexico, it took careful field research to discover
mosquitoes breeding in cast-off lye water containers. Likewise, it took years of painstaking local
observation to identify the specific dietary deficiencies causing pellagra.[89] If we are going to develop an effective
public health response to behavioral health epidemics, we will need to develop
a similar capacity to conduct careful field observation.
Local Action To Build Healthy
Communities. The physical infrastructure improvements
that we associate with the germ theory – e.g., plumbing and sewers and waste
treatment plants – are by definition local projects. In a modern parallel, “place-based
initiatives” target policies, investment and the development of social programs
to an identified community. These
initiatives are locally-driven, based on the belief that local leaders are best
positioned to identify local needs and effective strategies to build stronger,
safer, healthier and more economically viable communities.[90] “Place-based”
initiatives have been shown to be extremely effective. Examples include the Harlem Children’s Zone, an educational program for inner city
youth,[91] Communities that Care, a comprehensive
youth development program in Washington state,[92] and others that
provide models for this community based approach and convincing data regarding
their effectiveness. Most of the prevention
programs described earlier also rest on the willingness and ability of local
communities and/or local institutions for implementation. The Substance Abuse and Mental Health
Services Administration (SAMHSA) has developed a five-step “Strategic Prevention
Framework” designed to help states and local communities develop effective and
sustainable prevention programs. [93]
Policy Changes. By its very nature “public” health requires solutions that affect
everyone – many of which require the development of regulations, standards and
legislation. In the early days, public
health was primarily a local concern, and no two cities or states had precisely
the same policies. While the federal government periodically took action,
particularly when an epidemic threatened large areas of the country, the U.S.
Public Health Service wasn’t established until 1912, and wasn’t fully
federalized until the end of the Roosevelt administration.[94]
The public’s behavioral health today is significantly affected by
federal, state and local policies. For example, the federal Violence Against
Women Act, local and state statutes limiting smoking in public places, new
federal-state disaster planning requirements, mandated child abuse reporting
laws and the establishment of a refugee health and social service system - to
name just a few – have had a profound impact on the public’s health. An effective response to the epidemics of
today will require additional political action to stimulate the development of
a policy framework that effectively represents our current knowledge.
Development and Testing of
New Treatment and Prevention Techniques.
Any public health
problem seems daunting until the solution is identified and implemented. But the history of public health is replete
with inspiring stories of scientists conquering seemingly insurmountable
problems. Vaccines have been developed
for dozens of diseases, from smallpox and diphtheria to polio, rubella and
hepatitis B. Diseases caused by
nutritional deficiencies have been virtually eliminated through dietary change
or supplements. The development of
antibiotics and new antiseptic procedures profoundly changed medicine. While the situation today may seem overwhelming,
behavioral scientists display the same ingenuity shown by their predecessors. If we invest in research and development, the
number of effective tools available for both prevention and treatment would
grow accordingly.
Public Education. Education has always played a role in public health movements. Germ theory advocates quickly recognized that
even aggressive short-term measures would ultimately be ineffective unless the
public was educated about basic principles of hygiene. Courses were developed for primary and
secondary schools[95] and public health
reformers focused on educating the public about personal and family hygiene.[96] Contemporary public education efforts can
help disseminate information regarding research based strategies for managing
stress[97], early signs and
symptoms of illness and information regarding how to seek and obtain help for
these problems[98], workplace
wellness and employee assistance programs that can better prepare employees to
manage life changes[99]. Public education efforts like these can both
build individual resilience and develop a well-informed public that will
support policies that promote overall health and wellbeing.
SECTION VII. A SYSTEMIC APPROACH TO POLITICAL ACTION
Many of the
elements needed for a second public health revolution are in place. We have a theory, a causal model with
substantial evidence, and proven methods for prevention and treatment. Further research and development efforts are
clearly needed to devise, test and refine interventions to maximize
effectiveness as well as to fully elaborate the genetic and environmental
causal pathways and the neural mechanisms through which they work. However, important personal and social
benefits are now potentially available.
Failure to implement this knowledge is akin to ignoring problems with
food safety or failing to vaccinate against polio or smallpox. What steps are now needed to create public
momentum for a change of this magnitude?
The history of the public hygiene movement is instructive.
Cholera and
yellow fever, the diseases that provided the primary motivation for public
health reform, were not the diseases with the highest mortality rates –
tuberculosis and pneumonia caused more deaths.
Nor were they the only epidemics spread by unsanitary conditions –
diphtheria was a major epidemic disease throughout most of this period. However, diphtheria and other diseases like
scarlet fever, typhoid, malaria and tuberculosis had become familiar disorders
and the public had come to see them as inevitable. These endemic diseases lacked the drama of
the “great pestilences” and the general
population was resigned to their inevitability.[100]
In contrast, an
outbreak of cholera in any part of the world was enough to arouse newspapers,
medical societies and civic authorities in every American port. Americans closely followed the course of
cholera as it made its way through Russia and Eastern Europe to the Atlantic.
The newspapers were filled with “cholera stories” and the New York Times
editorialized on “cholera panics.” Other factors also heightened public concern
about the problem, including the collection of vital statistics and evidence of
the economic cost of sickness and death, illustrated vividly by epidemics of
yellow fever which effectively closed down southern cities and brought economic
activities to a halt. [101]
Virtually every
sector of society mobilized in response to the perceived threat. State and
municipal officials joined with medical societies to hold National Sanitary
Conventions which met from 1856 to 1860.
In 1884 President Chester Arthur issued a proclamation warning state
officials of the danger. Businessmen in
New York organized the “Sanitary Protection Society” to urge action. Others joined volunteer groups such as the
“Howard Association” (originating in New Orleans and soon spreading to other
southern towns and cities) to organize relief programs and provide medical
care, housing and food for families of those stricken. Municipal authorities initiated massive
sanitary campaigns and checked on food and water supplies. Voluntary sanitary associations sprang up
across the country to improve water and sewage systems, clean streets, provide
pure milk for infants and establish public health clinics. Congress passed the first national
quarantine act and a measure creating the National Board of Health. Philanthropic organizations, which had grown
with the accumulation of wealth by nineteenth century entrepreneurial
capitalists, applied their funds to further the development of scientific
models, and were a major force behind the mental hygiene movement. Change also occurred at the individual
level. Daily bathing, taboos against
spitting, new standards for personal and family hygiene and even a social
demand for more “personal space” have all been attributed to changing social
norms resulting from the public hygiene movement.[102]
None of these
changes came easily. Public health
reformers in the late 19th and early 20th centuries were
passionate advocates as well as scientists, and they fought for laws to support
their plans. They believed that “the
health of a community was the key measure of its success, and if pestilence and
death stalked even one small segment of the population, it was a stark
indication of the community’s political and social failure.”[103]
The forces
arrayed against public health reform must have at times seemed
overwhelming. While some progressive
businessmen recognized the long-term benefit of a healthy workforce, others
were concerned that implementing public hygiene measures would interfere with
business operations. Goldberger faced a particularly strong backlash from
southern businessmen who feared that publicity about pellagra would drive
investors and tourists away.[104] Opposition also came from people who were
generally anti-government or who saw public health measures such as vaccination
as a threat to individual rights. At times the issues were conflated with other
political issues, such as anti-immigration sentiment or tensions between the
north and the south. Surprisingly, one of the greatest sources of opposition
came from the medical community. Some
doctors had initially opposed the germ theory, feeling that it weakened their
personal authority over patients, but physicians came to provide strong
leadership for the growing public health movement. Nearly all of the early presidents of the
American Public Health Association were physicians.[105] Unfortunately, public health and medical care systems eventually
developed separate – and often oppositional – courses.[106]
The sheer
magnitude of the changes required was daunting to many. For example, when Goldberger began his
crusade to eliminate pellagra, public health authorities could not imagine
being able to change the eating habits of an entire population. For others, the theory of dietary causation
was simply too far removed from what they had been taught: “Having worshipped at the shrine of
bacteriology, they were unwilling to reconsider their basic assumption of
disease causation.” [107] Over time opposition of this nature faded, as
new intervention strategies emerged and social conditions changed. Pellagra was ultimately conquered when the
FDA established nutritional standards for white flour, including niacin, and
states began mandating enrichment. The poverty and specific diet that had caused
pellagra changed more gradually, but were eventually eliminated by post-war
economic growth.[108]
Over the long
term, public health measures waxed and waned with changing sociopolitical
circumstances. A strong middle class was
essential in support for public health, since without a middle class, the rich
simply lived “separate and unequal lives, maintaining clean and spacious homes
and using private systems of care.” In fact, the public’s health usually
worsens when the gap between rich and poor widens,[109] and some argue
that inequality itself is the primary public health condition to be addressed.[110]
Theory as a Tool for
Generating Momentum. The sanitarians that drained swamps and
built sewage systems were somewhat effective in preventing contagious diseases,
but without a clear rationale for why their measures worked, it was hard to
generate public support. Politicians
developed a pattern of investing money during an epidemic or crisis and cutting
funds when it died down, and advocates had “little choice but to await an
epidemic and, capitalizing on the public’s hysteria, twist the arms of
politicians and men of commerce in order to obtain the desired laws and funds.”[111] The germ theory made support for prevention
efforts more sustainable. Today, science
has established a causal mechanism linking environmental conditions to adverse
outcomes. Like the germ theory, this provides a basis for advocates to demand
the development and implementation of effective intervention technologies –
especially when coupled with evidence that our social order or national well
being is threatened.[112]
Building Coalitions. The theory described in this paper illustrates how individual
vulnerability when combined with chronic and toxic stress contribute not just
to one or two illnesses, but to a variety of interrelated conditions that are
seriously affecting our mental, general and economic health. It is clear that trying to eradicate one risk
factor to exclusion of others will ultimately be less productive than more
systemic approaches. Advocates may focus on violence against women, substance
abuse, violent crime or bullying, but all of these “toxic stressors” contribute
to the underlying problem. In the
public hygiene movement, public health measures were driven largely by a fear
of cholera and yellow fever, but most interventions – like clean water, safe
food and effective sewage systems – prevented dozens of different
diseases. Similarly, efforts to make our
communities safer, more inclusive, less toxic and less violent will help us to
reduce a number of problems that may appear to be distinct but aren’t.
It is also essential that we
address “treatment” and “prevention” as two necessary and interrelated
efforts. From a scientific perspective,
understanding the mediating role of toxic stress reminds us that effective
treatment for one individual often serves as prevention for others. From a political perspective, the alliance is
critical. Tension between public health
and health care ultimately resulted in the elevation of hospitals and
technology and the diminishment of public health and those specialties
associated with it.[113] Serious efforts need to be undertaken to
bring behavioral health treatment and prevention strategies and practitioners
into closer alignment.
Understanding the common
etiology of behavioral health and social epidemics makes it easier for
apparently disparate service systems to work together. Health and human service systems generally
work in isolation, each responding to one or more social or health problem
without recognition of their common antecedents. As long as the mental health system sees itsmission
as treating “mental illnesses,” the substance abuse system focuses only on
“addiction,” and the justice system defines their role as controlling “criminal
behavior,” forging effective, unified strategies is difficult, at best. Similarly, health care systems attempting to
reduce the burden of chronic illness, schools trying to improve academic
achievement and businesses focusing on increased productivity are unlikely to
see themselves as natural partners. But
when the underlying role of common risk and preventive factors is recognized,
potential linkages appear and natural partnerships emerge. For example, a
working group on women, violence and trauma - involving seven federal agencies and
dozens of departments and divisions - has found that the concept of
“trauma-informed care” provides a framework for effective collaboration focused
on creating healthier environments and more effective services.[114]
Creating Public Awareness
and Support. It has been argued that the most important
factor in the public hygiene revolution was the “sanitary-bacteriological
synthesis” that occurred in public consciousness. Average citizens may not have understood the
importance of the distinction between “miasmas” and “germs,” but they came to
understand that diseases were associated with conditions of dirt and filth, and
over time, the norms for community sanitation shifted.[115]
Currently, social determinants are not widely understood, and
behavioral health problems are often seen as irrational, self-destructive
behaviors rather than coping responses to toxic stress. Social policy and practice will shift when
the public comes to understand the relationship between toxic stress and the
social ills that plague our society today.
As a first step in developing public support a social marketing campaign
should be developed that identifies key audiences and develops and tests
messages that effectively communicate the urgency and opportunity provided by
our current knowledge. Use of
sophisticated behavior change strategies should be employed that are informed
by theories of change such as the transtheoretical model.[116] In this model, stages of change are
identified and messages/technologies are designed and implemented to stimulate
and support each stage of a change process.
It will also be critical to dramatically detail the effects of our
contemporary epidemics on the health and productivity of our communities and
nation. Providing local as well as
national estimates of wellbeing may be critical, and variations within local
areas (states or communities) may be particularly enlightening. Beginning in 2009, the Centers for Disease
Control (CDC) included an optional module on adverse childhood experiences in
their Behavioral Risk Factor Surveillance Survey (BRFSS), an extensive
telephone survey conducted through state health departments. The first report was released in December,
2010.[117] Demonstrating the linkages between causal
factors and health/social indicators builds a platform for local action. At least one state, Washington, has used
state level ACE data to inform new policies and program development across
juvenile justice, education, child protective services and rehabilitation
services.[118]
Mobilizing All Sectors for
Local Action. Federal, state and local governments;
community and volunteer groups; providers and professional associations; the
business community; and private philanthropy all have roles to play. New platforms need to be considered that strengthen
the community’s capacity to reduce and contain the multiple “pathogens”
underlying today’s epidemics as well as strengthening the population’s
resilience to these “infectious” agents.
This can best be done by involving local community leaders in
identifying their own priorities for action, developing their own intervention
strategies and individualizing measures of progress. Support for the development of local
coalitions to address local problems will be essential; for example, supplying
simple, usable technologies for needs assessment and the selection of community
targets. The use of tested technologies
will assist implementation at the community level.
State health departments working with juvenile justice, corrections,
education, labor and community and economic development must also examine their
policies and incentives to help assure that they are in harmony and support the
development of overall community well being.
Substantial infrastructure exists to pursue the sector-specific aims of
these agencies. This infrastructure must
be adjusted to support these broader goals and technologies. Use of costing models that better represent
the full governmental costs and benefits of programs rather than those that
accrue to a particular sector (see for example the Washington State example)[119] might help to
develop the empirical platform that can be used at a state level to motivate
action and evaluate results.
The call for a public health approach to behavioral health is not
new. In 1979 and 1980, in a two-volume
report titled Healthy People, Surgeon
General Julius Richmond called for “a second public health revolution” focused
on diet, smoking, drug abuse, exercise, accidents and safety, and setting
public health goals including reducing infant mortality, etc. Thirty subsequent years of research has now
given us the scientific basis to realize this vision.
Ultimately, an effective public behavioral health response will depend
on a strong overall public health system. Unfortunately, we have allowed our
public health system to fray over the past decades. As one author put it: “These (public health)
crusaders would find it amazing to witness the erosion of America’s public
health infrastructure during the later 20th century, the low status
ascribed to public health physicians and scientists, the legal limitations
placed on their authority, and the disdain with which American’s viewed their
civil servants.”[120] Our best hope for addressing the epidemics of
today rests on the re-establishment of a strong public health system – and one
with a strong behavioral health component.
Conclusion. The United States is facing a series of
challenges that are undermining the health of our citizens and our leadership
in the world. Like the people of the
mid-19th century, we’ve become accustomed to these endemic,
pervasive personal and social ills. We
are suffering the consequences of problems that are, in fact, preventable. Just as a wide variety of stakeholders in the
mid-19th century rallied behind the “germ theory” to initiate a
broad social reform effort, we must now begin to educate community, state and
national leaders to the situation facing us. Our national and local leaders
need to understand the insidious effects of our contemporary social epidemics
and the theory that underlies their development. Perhaps most importantly, they
need to become informed about the effective, validated technologies that are
already available – technologies that can reduce the prevalence of health,
behavioral health, and social problems, strengthen pro-social behaviors and
create the community cohesion needed to buffer the effects of toxic stress and
trauma. Making the practical changes
necessary to improve our health and preserve our world leadership is well
within the American spirit of ingenuity and accomplishment. We need to call upon the spirit and
determination that built America to rally behind a new public health agenda and
to address our current personal and social challenges. We clearly can and must do it now.
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