The Moore Tornado Reminds Us That "Sheltering" Is A Community-Level Concern

As the news of the Moore, Oklahoma tornado flooded in on Monday, the images were terrifying.  Over and over, Meteorologists kept saying- "it would be very hard to survive this storm above ground".  And then we heard that basements and safe rooms are not common in Moore.  Safe rooms being structures that are reinforced to withstand 200+ MPH winds.

So how can that be?  How can a town situated in an area of the country ripe with tornado activity be without basements and safe rooms?

Well- as with most public health challenges, the answers are complex:

Environmental:  The soil in the state is comprised mostly of clay.  The bedrock is mostly limestone.  Both absorb water and become unreliable foundations for a basement.

Urban Sprawl:  As The Atlantic points out, "One reason tornadoes prove so deadly now is that, given the spread of the suburbs, their funnels simply stand a better chance of touching down where people are".  Therefore, instead of striking farmland, these tornadoes are striking homes and schools and shopping centers- many without sufficient sheltering options.

Cost: Various estimates have been given over the past two days, but NBC News reports that individual home safe rooms can cost $8,000-$10,000 to construct.  There is a lottery to receive state assistance for these costs.  The most recent lottery selected 500 homeowners...out of 16,000 applications.  The city of Moore recently applied for $2 Million in federal aid to help build safe rooms in an additional 800 homes.  City officials report that the program was delayed because FEMA standards were a "constantly changing target".

There are additional cost challenges at the community-level.  NBC News reported that it would cost $1.4 Million to construct safe rooms in each school.

Access:  The City of Moore has no community (or "public") tornado shelters.  On their website, they attribute this to two reasons:  (1) People take less risk by sheltering in place and (2) There is no public building in Moore that is suitable for a shelter.

With hindsight being 20/20, it is heartbreaking  to read the following statement on their site:

"Statistically, there is only about a 1-2% chance of a tornado - of any size - striking Moore on any particular day during the spring. But of all tornadoes that do strike us (again, not very many historically), there's only a less than 1% chance of it being as strong and violent as what we experienced on May 3rd [1999]".  

Interestingly, "May 3rd" (as it is often abbreviated), shined a light on the need to shift from individual (family) shelters only to community-level ones.  Shortly after that storm, FEMA released design and construction guidance for community safe rooms.  Many communities, such as nearby Tushka, OK, have constructed such rooms very successfully.

In public health, we assess health needs and change the conversation from individual-level to community-level solutions.  We need that frame of mind to improve emergency preparedness planning for tornadoes.  As Megan Garber writes for The Atlantic:

"The old, Wizard of Oz-style model of sheltering -- every farm with its cellar -- is slowly giving way, in the age of suburban sprawl, to large shelters meant to house large groups of people".    

"Sheltering, in other words, is moving from an individual concern to a collective one". 


Tell Me What You Think:

• What are some solutions to the challenges (environmental, cost, access) listed above?
• What is your reaction to the shift from individual to community-level shelters?

Angelina Jolie's "Medical Choice" Dominates the Internet

I woke up this morning to the quintessential Pop Health story.  Angelina Jolie published an op-ed called "My Medical Choice" in the New York Times.  She talks about undergoing a preventative double mastectomy in February 2013 after genetic testing revealed that she carried the BRCA1 gene.

As I inventoried her column and the online chatter today, I worried that I missed the boat!  Dozens of bloggers and news outlets wrote about her op-ed within hours of its posting...what else could I add to the conversation?

With so many posts for readers to sift through- many of which focus on very specific issues (e.g., the efficacy of preventative mastectomies)- I decided to add to the conversation by cataloging the public health implications being discussed:

Angelina as a "champion" for breast cancer prevention: will her celebrity status help or hurt the cause?:  Most of the articles and comments that I read in response to her op-ed were overwhelmingly positive.  This is exemplified by an open letter on KevinMD.com written by Dr. James Salwitz.  He praises Angelina for her bravery and leadership in the battle against breast cancer.  He goes on to state, "Your action will save more lives than all the patients I could help, even if I were to practice oncology for hundreds of years".  On the flip side, a few writers/commenters raised the concern that Angelina's influential status in conjunction with her decision to have surgery could cause women to panic about their own breast cancer risks.  For example, David Kroll writes for Forbes, "For all the bravery of Ms. Jolie and the positive groundswell that her op-ed generates, I also want to be sure that women with breast cancer - women who are already scared - do not feel the extra burden that they’re not doing enough if they don’t consider a double mastectomy".

I thought that Linda Holmes (of NPR's pop culture blog) did a really nice job of reconciling Angelina's role as both "celebrity" and "champion" in her post called "Why Angelina Jolie's Op-Ed Matters".

Legal and Policy Issues:  BRCA Genetic Testing:  On April 15, 2013, the Supreme Court heard oral arguments challenging Myriad Genetics' patents on "the breast cancer genes".  As a side note: I do not remember hearing about this story last month- perhaps because the Boston Marathon bombings also took place on April 15th?  The concern is that such patents inhibit scientific advancements, keep testing costs high- and therefore limit access to the testing.  Angelina alludes to this in her op-ed when she reveals that the BRCA1 and BRCA2 testing costs approximately $3,000 in the U.S.  Sarah Kliff from The Washington Post notes that this testing "is about to get significantly less expensive: The Affordable Care Act included the genetic test among the preventive services that insurers are required to cover without any cost sharing".

Health Communication- Risk Perception:  Nancy Shute wrote an interesting piece for NPR entitled, "Angelina Jolie and the Rise of Preventative Mastectomies".  She interviews Dr. Todd Tuttle, who raises concerns about women overestimating their risk of breast cancer (in the other breast after being diagnosed on one side) and choosing more invasive treatment like mastectomy when not medically necessary.  Shute also discusses some potential contributors to the increases in risk perception and preventative mastectomy. For example, she mentions advancements in breast surgeries/reconstructions and the "hyper-awareness" of breast cancer resulting from ubiquitous pink ribbon campaigns.  Many of these contributors were discussed two weeks ago in the must-read The New York Times Magazine article "Our Feel Good War on Breast Cancer" by Peggy Orenstein.

Reviewing the Evidence Base for Recommending BRCA Testing or Preventative Mastectomies:  Many articles focused on reviewing what we know about the effectiveness of (1) BRCA testing for predicting cancer and (2) mastectomies for preventing cancer death.  Several articles linked to the CDC feature, "When is BRCA Genetic Testing for Breast and Ovarian Cancer Appropriate"?  Sarah Kliff discusses why "Most Women Probably Shouldn't Get the Cancer Screening Angelina Jolie Did".  NPR linked to a 2010 Journal of the American Medical Association (JAMA) article that provided the "clearest evidence yet that women carrying the BRCA1 and BRCA2 genes should consider preventive surgery because they are at a very high risk for breast and ovarian cancers."

With so many articles and blogs to sift through, I could probably keep going.  But I'd like to stop and hear from you:

• What other public health implications could result from Angelina Jolie's disclosure in today's New York Times?
• How do you think her disclosure could impact the issues I've raised above- risk perception, policy decisions, etc?
• I've linked to some of the articles that I read today- are there others that you would recommend to me and Pop Health readers?

"Call the Midwife": Public Health in the 1950s and Today

Are other people in love with "Call the Midwife" like I am?  I started watching last year during a break between Downton Abbey seasons.  The show follows the lives and work of nurse/midwives working in the Poplar community of east London in the 1950s.  The community has a high poverty rate and limited resources.  The series is based on the memoirs of Jennifer Worth, who like the main character Jenny Lee, became a midwife at the age of 22.

Season 2 of Call the Midwife (airing in the U.S. March 31-May 19, 2013) has been packed with public health issues.  I have been struck by how many of the highlighted issues still challenge us today:

• Season 2, Episode 1: Jenny Lee begins to care for a young mother named Molly, pregnant with her second baby.  In the course of their visits, Jenny realizes that Molly is a victim of domestic violence.  In one especially poignant scene, Jenny soothes and encourages Molly via a conversation held through the family's mail slot. Molly has been ordered by her husband not to let Jenny in the house.

Domestic violence (or intimate partner violence- abuse by a current/former partner or spouse) is still a problem today.  The Centers for Disease Control & Prevention (CDC) estimates that it affects millions of Americans.  This violence has long-term economic and health consequences for individuals, families, and communities.  The CDC offers many resources focused on public health's role in the prevention of intimate partner violence.

• Season 2, Episode 5: Jenny Lee provides prenatal care to Nora, a mother of 8, living in poverty.  The family of 10 crowds into a 2 room flat.  When Nora finds out that she is pregnant again, she is desperate to end the pregnancy.  With the family's financial situation, she feels that it is impossible for her family to take care of another child.  Jenny confronts Nora after seeing evidence of self harm.  Jenny reminds her that there is only one way to terminate a pregnancy (abortion), but it is illegal.  Nora risks her life seeking the services of a local woman who performs abortions.

Abortion remains a hotly debated public health issue in the U.S. both at the state and federal level.  This episode of "Call the Midwife" is a grim reminder of what can happen when women do not have access to safe, legal abortions.

• Season 2, Episode 6:  After diagnosing several late-stage Tuberculosis (TB) infections in Poplar, the community physician (Dr. Turner) advocates for a screening program in the form of an x-ray van.  Dr. Turner and Sister Bernadette (a nun/midwife) make a wonderful public health argument for the resources they need.  They cite the risk factors, specifically poverty in their community, noting that families may have up to 12 people in one apartment.  The close living quarters increase the chance of spreading this infectious disease.  In fact, we meet one family in the episode that lost 6 children to TB.  As a public health professional, it was fascinating to see the promotional materials that the clinicians created to recruit people for the screening.  They papered local bars with flyers and set a large sign outside the van reading, "Stop. 2 minutes may save your life. Get a chest x-ray".

Infectious diseases and their screening, treatment, and vaccination remain key public health issues in the U.S. and around the world.  Many infectious diseases like measles or chickenpox can be prevented by vaccines.  Over the past 15 years, there has been much discussion between the public and public health communities about the safety of vaccines for children.  In January 2013, the Institute of Medicine released a report reaffirming that the current childhood vaccine schedule is safe.  In fact, they report that "vaccines are one of the safest public health options available".

Tell Me What You Think:

• What have been your favorite episodes of "Call the Midwife"?
• What other public health issues are portrayed in the 1950s that still challenge us today?

Kudos to The New York Times Magazine for Examining the "Feel-Good War" on Breast Cancer!

In last week's The New York Times Magazine, Peggy Orenstein wrote an article called "Our Feel-Good War on Breast Cancer".  The piece is lengthy but well researched, insightful, and well worth the reading time.

Peggy, a breast cancer survivor herself, hits every key public health issue- cancer screenings, treatment options, "awareness" raising, message framing, funding, and research.  As someone who has been critical of "awareness" raising, I was happy to see the issue discussed front and center.  For me, her interview with Dr. Gayle Sulik (Sociologist and Founder of the Breast Cancer Consortium) was the most striking.  A key quote from Dr. Sulik (I added the bolding):

“You have to look at the agenda for each program involved.  If the goal is eradication of breast cancer, how close are we to that? Not very close at all. If the agenda is awareness, what is it making us aware of? That breast cancer exists? That it’s important? ‘Awareness’ has become narrowed until it just means ‘visibility.’ And that’s where the movement has failed. That’s where it’s lost its momentum to move further.”

Peggy also tackles the issue that is an ongoing challenge in public health and medicine:  screening.  Screenings are tests that look for diseases before you have symptoms.  Ideally, screening will identify diseases early when they are easier to treat and have better outcomes.  For breast cancer, the key screening test is a mammogram (x-ray of the breasts).  However (as Peggy points out), we seldom hear about the research that demonstrates limited effectiveness of mammograms for reducing cancer death.  This is not the research cited in the communication materials from advocacy organizations.  We also tend not to hear about the negative side effects of screening large segments of the population.  There can be false positive tests: which subject the patient to unnecessary medical intervention and emotional distress.  There can also be over-treatment for the detected cancer, even if it turns out to be a non-aggressive tumor.

When I was working in suicide prevention, one of the best articles I read was "Screening as an Approach for Adolescent Suicide Prevention" by Dr. Juan Pena and Dr. Eric Caine.  The authors dedicate a section of the paper to key decisions and tasks to resolve before implementing a screening program.  While the public health issue and screening tests are different, I believe many of their decision points are generalizable to almost any health issue.  The table presenting these decisions and tasks is a great reminder to public health professionals and clinicians that recommending and undertaking a screening program should be strategic and the decision should be re-visited regularly.  For example, the authors highlight:

• Key Decision:  Population and Setting- Is the screening program consistent with the target population's community or cultural values?
• Key Decision:  Screening Instrument- What will be the false positives and false negatives rates in the population to be screened?  Are these rates acceptable?
• Key Decision:  Staffing and Referral Network- Are there effective treatments available for the types of conditions being screened for?
• Key Decision:  Quality Assurance- How will the screening program be monitored to ensure that protocols are followed?
• Key Decision:  Legal and Ethical Issues- Has sufficient informed consent been given to parents and youth about risks, benefits, and limits of screening?

Going back to the "Feel-Good War" article:  I like that Peggy did not just point out all the flaws in our current breast cancer screening and treatment systems.  Instead, she invited her interviewees to recommend potential improvements.  Some ideas were noted in two key areas:

• Message Re-Framing:  Rather than offering blanket assurances that “mammograms save lives,” advocacy groups might try a more realistic campaign tag line. The researcher Gilbert Welch has suggested this message, “Mammography has both benefits and harms — that’s why it’s a personal decision.”

• Funding Re-Distribution:  Peggy asked scientists and advocates how some of that "awareness" money could be spent differently. She highlights the February recommendations of a Congressional panel (made up of advocates, scientists and government officials) that called for increasing the share of resources spent studying environmental links to breast cancer. They defined the term liberally to include behaviors like alcohol consumption, exposure to chemicals, radiation and socioeconomic disparities. 

Tell Me What You Think:

• What do you think about the "pink culture" or awareness raising around breast cancer?  Will it effectively lead us to our goal of prevention?
• In addition to message re-framing and funding re-distribution, what else would you recommend to help improve the approach to breast cancer prevention, screening, and treatment?

"Call Me Crazy": Lifetime's New Movie That Champions Hope and Resilience Around Mental Illness

*Warning: it was difficult to write this post without including a few small spoilers, but I hope you'll watch the whole film anyway.

On Saturday April 20th, Lifetime debuted "Call Me Crazy: A Five Film".  The film (which boasts a star-studded cast and director list) includes five short stories that examine the impact of mental illness from various perspectives.  Each story is named after the main character: "Lucy", "Grace", "Allison", "Eddie", and "Maggie".

In the first story, we are introduced to Lucy (played by Brittany Snow).  Lucy, a law student, has recently been admitted to a psychiatric institution after experiencing a schizophrenic episode.  She is struggling to see how she can live a "normal" life that includes relationships and a career.  Her clinician encourages her to finish law school because she has insight into something very few people understand (mental illness)- so who knows how many people she could help?

In "Grace", we meet a daughter who has been living with a bipolar mother for her entire life.  Grace is played beautifully by Sarah Hyland from "Modern Family"- I loved seeing her in a dramatic role.  We see the "highs" and "lows" of her mother's condition.  We also see the devastating impact that it has on Grace's life when it is not treated.  Grace often plays the role of caretaker- making sure her mother is safe.  We see her struggle to have her own life aside from her mother's illness.

"Allison" offers the viewers a twist.  She plays Lucy's younger sister.  So we step back from Lucy's view and we see how mental illness has affected her entire family.  Allison's childhood, her sense of safety, her relationship with her parents- were all changed as a result of her sister's illness.  She has bottled up a lot of anger and finds it difficult to support her sister through her recovery.

"Eddie" introduces the only male main character.  He is suffering from severe depression.  He has withdrawn from his wife and his friends.  He has stopped receiving help from his therapist.  We watch his wife intervene after discovering that he may be thinking about suicide.

Finally, "Maggie" introduces topics that (unfortunately) are all too common these days- post traumatic stress disorder (PTSD) and military sexual trauma among our returning veterans.  Maggie (played by Jennifer Hudson) was victimized during her time in the Army and its lasting impacts are threatening her ability to have a healthy relationship with her family.  Here we get another update on Lucy- she is now a lawyer and is representing Maggie in court.

While each story stands on its own, Lucy's story is woven throughout "Allison" and "Maggie" as well.  I really liked this strategy.  Not only because I became invested in her character during the first story...but also because seeing her evolve over time helped to demonstrate some key themes from this film- hope and resilience.

As Lucy says to Maggie: "I am living proof". [Of what?] "That there is hope".  In court, Lucy reminds Maggie's judge that having mental illness does not mean that you are a bad person or a bad mother.  She also reminds him about the importance of social support, "it is nearly impossible to get well alone".  Even though we see all of these characters at their lowest point- there is still hope that they can feel better, have strong relationships, and contribute positively to the world.

It seems fitting that Brittany Snow's character delivers these messages about hope and resilience, as she is a strong advocate for them in real life.  Together with the Jed Foundation and MTV, she founded Love is Louder.  Love is Louder is an inclusive movement that amplifies messages of love and support to combat negative messages resulting from bullying, loneliness, and stigma.  She has also publicly shared her own battles with anorexia, depression, and self harm.

As a health educator, I highly recommend this film as a resource for discussing mental illness, suicide, stigma, social support, and help-seeking.  Since each story is approximately 20 minutes, they can be broken down into segments or watched all together.  This film is a great example of Entertainment Education, which is an area of public health that acknowledges the strong impact that television and movies play in educating the public about health issues.

If you or someone you know is struggling with a mental illness, please reach out:
National Suicide Prevention Lifeline (1-800-273-8255)

Emergency Response to the Boston Marathon Bombings: Looking to Social Media for Information, Resources, and Connections

Boston is my second home.  I lived there for 6 years.  I went to school there.  I made some of the best friends of my life there.  I got married there.  I spent many Marathon Mondays along the race route cheering for friends, colleagues, and absolute strangers.  As many have reported on the news, Marathon Monday is the best day of the year in Boston and you have to experience it to truly understand its excitement and feeling of community.

I am absolutely heartbroken about yesterday's bombing at the Marathon.  In tears, I sat and watched the news alone in my home.  However, I did not feel alone.  As news broke, I quickly connected with Boston friends via text and social media to make sure they were okay.  Many had been watching at various points along the route.  I also connected with public health colleagues to follow the news and to catalog resources and information being deployed to my friends in Boston and also to those of us watching from home.

As with Hurricane Sandy last November, I think it is important to document all the ways that social media is being used to disseminate information and support public health and emergency management.  Here are the key themes that I saw:

Immediate Public Safety Concerns and Instructions

With the #tweetfromthebeat hashtag, Boston Police communicated regularly with twitter followers, instructing marathon spectators to clear the area around the finish line and refrain from congregating in large crowds.

Investigation

To assist with the investigation, Boston Police and FBI are asking all spectators and eyewitnesses to submit video and photos taken at the finish line.  This message has been widely disseminated via social media.

Reconnecting Runners, Spectators, and Resources

As we have seen with emergency management of natural disasters, social media and technology play a critical role in reconnecting victims with their families and friends.  For example, the following resources were quickly deployed on social media:

• American Red Cross: Safe and Well
• Google: Person Finder
• Google document: Local Boston residents offering shelter to displaced runners/friends/families

Resources for Journalists

Along with tweets from respected news organizations and reporters reminding each other not to speculate early on in the investigation, there were also formal resources circulated regarding how to effectively cover such a story.  For example, the Dart Center for Journalism & Trauma offers comprehensive resources on the reporting of disasters and terrorist attacks.  A resource focusing specifically on the Boston Marathon bombings was tweeted out:

Mental Health & Support Resources

Many public health professionals linked to resources to support those in distress following the bombings and/or those who needed help communicating about the events (e.g., discussing it with children).

HHS Secretary Sebelius tweeted about federal disaster resources:

Philadelphia (like many other cities) tweeted about local disaster resources:

Massachusetts General Hospital and other organizations tweeted out tips for discussing the Boston Marathon bombings with children:

As I discussed in my coverage of Sandy, the power of social media also brings challenges to public health and emergency management.  We have seen some early postings about the lessons learned from this event- which does include a discussion of concerns such as rumors spreading rapidly on social media.  For example, it was first reported that cell coverage in Boston was being turned off so that additional bombs could not be detonated remotely.  We later learned that information was not true.  The cell service was slow or not operational due to the extreme overload of users trying to communicate simultaneously.  There was also a lot of concern about very disturbing images of the crime scene and victims being shared on social media.

So there is much to learn about the use of social media for public health and emergency management through close examination of this event and others.  In any case, it is very clear that social media needs to be a part of every organization's disaster and response plan. 

Tell me what you think:

• What was your impression of the use of social media by federal/state/local organizations yesterday after the Boston Marathon bombings?  
• Can you share additional examples of how it was used effectively?  
• What did you see that concerned you?

Social Media: Providing Connections, Voices, Adventures to Many with Chronic Illness

I am in awe of social media.  

I am in awe of it in my professional life.  I have connected with colleagues all over the world who share my passion for public health, health communication, blogging, pop culture- you name it.

I am also in awe of it in my personal life.  As someone who lives with a chronic illness, I have connected with others who suffer from similar symptoms, offer support, advocate for patient rights, and recommend creative solutions to balancing work and life.

In the past month, I have been struck by several examples of how social media is transforming the lives of people with chronic illness.  Without the networks available within social media, many of these people may have been very isolated due to their conditions.

On March 11, 2013 NBC Nightly News with Brian Williams ran a story about Virtual Photo Walks.  The project's tagline is "Walk the walk for those who can't".  Using the social media platform Google+, Virtual Photo Walks enables people to become "interactive citizens" again.  They connect with smart phone enabled photographers to "travel" and see places and people that they used to see...or always wished that they could.  The news story profiled a woman with Lupus who could not travel due to her serious health condition.  She always wanted to go to Italy and with Google+ she did.  We watched World War II veterans no longer able to travel, "visit" the USS Arizona Memorial through the collaboration of photographers and Google +.  It was incredible to watch.    

On April 5, 2013 CNN Tech ran a story called "On Twitter, Roger Ebert Found a New Voice".  The story describes how Roger became an avid twitter user in 2010, years after cancer had silenced his voice.  He wrote, 

"Twitter for me performs the function of a running conversation. For someone who cannot speak, it allows a way to unload my zingers and one-liners".

As someone growing up in the 80's, I regularly watched "Siskel and Ebert and the Movies".  Keeping up with Roger through twitter and his blog "Roger Ebert's Journal" in recent years has been a seamless transition.  I felt like the show never ended.  I kept up with his running commentary and of course- his movie reviews.

Sustaining your presence in the world is important with a chronic illness.  I felt that point strongly when reading his final blog post, "A Leave of Presence".  

"What in the world is a leave of presence?  It means I am not going away".  

Please Share:

• What creative ways do you see social media being used to support those with chronic (or acute) illnesses?
• Why do you think these communication channels are so effective in "sustaining your presence"?