For anyone who has ever had a mammogram, reminded someone to have a mammogram or sported anything pink for breast cancer awareness month, the New York Times has a thought-provoking article well worth reading. The author battled breast cancer twice and raises the interesting and controversial question of whether the uber-awareness campaign about breast cancer led to more mammograms than were necessary. The author argues that mammograms can result in early treatment—which comes with its own risks—but ultimately doesn’t save many lives. Studies cited show many women died despite early detection and many others, who underwent years of treatment for breast cancer, might never have been bothered by their breast tumors at all.  

The article arrives on the heels of a study in the journal Cancer that found that the proportion of women undergoing screening for breast cancer every year did not change after the U.S. Preventive Services Task Force advised that there was not enough evidence to support routine mammograms for women in their 40s.

Otis Brawley, chief medical officer of the American Cancer Society, weighed in on the Times article on the ACS Press room Blog and agreed that it is recommended reading: “This is a powerful and important article, one I believe every breast cancer advocate, and frankly even advocates for prostate and other cancers, should read,” wrote Brawley. “ It lays out the challenge that lies before us in reducing death and suffering from breast cancer, while demonstrating the challenge that we in public health face in how to accurately and truthfully administer information.”

>>Read the article.

FDA Approves Plan B One-Step for Women 15 and Older
The U.S. Food and Drug Administration (FDA) has approved over-the-counter use of the Plan B One-Step emergency contraceptive for women age 15 years or older. The single dose pill previously required a prescription. “Research has shown that access to emergency contraceptive products has the potential to further decrease the rate of unintended pregnancies in the United States,” said FDA Commissioner Margaret A. Hamburg, MD “The data reviewed by the agency demonstrated that women 15 years of age and older were able to understand how Plan B One-Step works, how to use it properly, and that it does not prevent the transmission of a sexually transmitted disease.” Last month a federal judge in New York ordered the FDA to make Plan B available to all women and/or make Plan B One-Step available “without age or point of sale restrictions,” according to an FDA release. Read more on teen pregnancy.

Study: Amusement Rides Injure 4,000 U.S. Kids Annually
As the weather warms and families start to plan summer vacations, it’s important for parents to remember to use caution when selecting amusement park rides. More than 4,000 kids are injured on an amusement ride each year in the United States, according to researchers at the Center for Injury Research and Policy at the Research Institute at Nationwide Children's Hospital in Columbus, Ohio. Injuries sent about 93,000 children to emergency rooms between 1990 and 2010, with about 70 percent of those coming May through September. Researchers say the numbers demonstrate the need for standardized safety regulations. "Although the U.S. Consumer Product Safety Commission has jurisdiction over mobile rides, regulation of fixed-site rides is currently left to state or local governments, leading to a fragmented system," said senior author Gary Smith, MD, director of the Center for Injury Research and Policy, in a release. "A coordinated national system would help us prevent amusement-ride-related injuries through better injury surveillance and more consistent enforcement of standards." The study includes safety tips for parents. Read more on safety.

Prevention App Wins HHS Challenge
The winner of the a recent mobile app challenge from U.S. Department of Health and Human Services (HHS) Office of Disease Prevention and Health Promotion is the myfamily app developed by Lyfechannel, a company that translates evidence-based health behavior and adherence studies into mobile applications. App users can find prevention information and tips for each member of their family; create personal health alerts; and keep track of medical check-ups and vaccinations. HHS research shows that patients who are better engaged in their own health care have better health outcomes and that electronic tools can help them be better health consumers. Read more on prevention.

Each year hundreds of public health researchers and practitioners meet to share research and best practices on creating a stronger public health system at the annual Keeneland Conference in Lexington, Ky. The conference, which will be held this year April 8-11, is sponsored by the National Coordinating Center for Public Health Services and Systems Research, based at the University of Kentucky.

Paul Kuehnert, MS, RN, senior program officer and director of the Public Health Team at the Robert Wood Johnson Foundation (RWJF), will speak at the opening lunch about threats and opportunities for public health, and how we can re-shape the system to create a healthier future for all. We caught up with him to get his insights before the conference on the evolving role of public health. Prior to joining the Foundation, he was county health officer and executive director for health for Kane County, Ill., where he led a partnership between the health department, hospitals and other partners to assess and address the community’s health needs. Kuehnert is a Pediatric Nurse Practitioner and worked as a primary care provider in schools and other community settings in Missouri and Illinois. 

NewPublicHealth: What are you going to talk about at Keeneland?

Paul Kuehnert: I think a lot of us are familiar with the data on our health care system, and the inter-twined issues of access, quality and cost. And the fact that younger Americans have a lower life expectancy than young people in other developed countries. We’re just not getting the health outcomes that one would expect from the amount we’re spending.

When you pit that against our legacy in public health, and what’s happening in the environment we operate in, I think there’s a real need to identify the threats and opportunities and re-imagine what we’re doing. We’re working from old models that need to be really questioned. What I’m hoping to do, and that others will do, is to provoke some creative thinking about where we need to go in public health to truly meet the challenges that face our communities and our nation.

NPH: What do you see as some of the major public health challenges today?

Kuehnert: For me, one of the first that comes to mind is that issue of life expectancy. With all the resources we have, we’re actually losing ground. It’s extremely concerning and has to do with a number of underlying dynamics—but particularly the epidemic of chronic disease, things such as obesity, heart disease, cancer, and all of those threats to our health. And there are also the incredible health disparities, the inequities that are reflected in our health across the country.

Yesterday, New York State Health Commissioner Nirav R. Shah, MD, MPH, released the 2013-17 Prevention Agenda: New York State’s Health Improvement Plan—a statewide, five-year plan to improve the health and quality of life for everyone who lives in New York State. The plan is a blueprint for local community action to improve health and address health disparities.

Dr. Shah was joined by New York City Health Commissioner Thomas Farley, MD, MPH, and representatives from leading health care and community organizations at the Charles B. Wang Community Health Center in Manhattan. Among the other speakers were Jo Ivey Boufford, MD, president of The New York Academy of Medicine, and Daniel Sisto, president of the Healthcare Association of New York State.

 >>Read a related Q&A with Commissioner Nirav Shah.

“We’ve all heard the adage—an ounce of prevention is worth a pound of cure,” said Commissioner Shah. “We need to fundamentally change the way we think about achieving better health in our society.”

That fundamental shift toward prevention, said Dr. Shah, requires setting clear goals, promoting active collaborations, and identifying policies and strategies that create opportunities for everyone to live a healthy life.

The Prevention Agenda identifies five priority areas:

• Prevent chronic disease
• Promote healthy and safe environments
• Promote healthy women, infants and children
• Promote mental health and prevent substance abuse
• Prevent HIV, STDs, vaccine-preventable diseases, and healthcare-associated infections

A health improvement plan like the one released by the New York Department of Health is a critical prerequisite for public health department accreditation. Recently, the Public Health Accreditation Board awarded five-year accreditation to 11 public health departments. Those 11 are the first of hundreds currently preparing to become accredited, including New York state.

"Completing the accreditation application, which includes our Prevention Agenda 2013-17, provides the Department of Health a valuable opportunity to engage partners and community stakeholders in our ongoing efforts to improve public health, evaluate the effectiveness of our services and showcase our successes," Commissioner Shah said.

Today, New York State Health Commissioner Nirav R. Shah, MD, MPH, released the 2013-17 Prevention Agenda: New York State’s Health Improvement Plan—a statewide, five-year plan to improve the health and quality of life for everyone who lives in New York State. The plan is a blueprint for local community action to improve health and address health disparities, and is the result of a collaboration with 140 organizations, including hospitals, local health departments, health providers, health plans, employers and schools that identified key priorities.

Dr. Shah, the architect behind today’s prevention agenda, was confirmed as New York State’s youngest Commissioner of Health two years ago. The state’s governor, Andrew Cuomo, had three critical goals: reduce the state’s annual Medicaid growth rate of 13 percent, increase access to care and improve health care outcomes.

Shah, a former Robert Wood Johnson Foundation Physician Faculty Scholar and Clinical Scholar, has already made important inroads in all three goals and the prevention agenda builds on that. NewPublicHealth spoke with Dr. Shah about prevention efforts already underway in the state, and what it takes to partner health and health care to achieve needed changes in population health.

NewPublicHealth: How does improving the social determinants of health help you achieve your goals in New York State?

Dr. Shah: New York’s Medicaid program covers 40 percent of the health care dollars spent in the state. We were growing at an unsustainable rate, and we needed a rapid, but effective solution. So, we engaged the health care community, including advocates, physician representatives, the legislature, unions, management, and launched a process that enables continuous, incremental, but real change toward the Triple Aim—improved individual health care, improved population health and lower costs.

Collectively, these efforts resulted in a $4 billion savings last year in the State’s Medicaid program, increased the Medicaid rolls by 154,000 people, and resulted in demonstrable improvements in quality throughout the system.

NPH: What opportunities do you see for public health and health care to work together in New York State?

While this is the first year that the American Public Health Association has used “return on investment” as the theme for National Public Health Week, which runs through April 7, it’s far from the first time that public health practitioners have made the case to policymakers that the work of public health can save lives and money.

Research on the impact of public health services includes the critical fact that spending just $10 per person in programs aimed at smoking cessation, improved nutrition and better physical fitness could save the nation more than $16 billion a year, according to the Trust for America’s Health. That’s a nearly $6 return for every $1 spent.

Over the last two years, NewPublicHealth has reported frequently on the value of investing in public health. Some of our favorite ROI articles, reports and other resources include:

• >>UPDATE: Trust for America's Health released Investing in America's Health: A State-by-State Look at Public Health Funding and Key Health Facts today. The report examine public health funding and key health facts in states around the country, finding inadequate and cut funding and wide variation in health outcomes by state and county.
  
• Making the Case for Prevention: A Q&A with James S. Marks, Senior Vice President, Robert Wood Johnson Foundation, about the great potential for investing in prevention.
  
• National Prevention Resources Starter Guide:
  A collection of resources that showcase how different fields can work together and take action to prioritize prevention.
  
• Strategies to Move from Sick Care to Health Care: The  Trust for America's Health identifies high-impact steps that the nation can take to prioritize prevention and improve Americans' health.
• Workplace Wellness Perspectives: A Q&A with two very different businesses—one big, one small; one academic, one industrial—on creating healthier workplaces.
• Employers Join Community Health Movement: A Q&A with Trust for America’s Health and the National Business Coalition on Health about the critical role of employers in community prevention efforts.
• Stories of the value of investing in prevention from Wyandotte County, Kan., and Hernando, Miss.

>>Read more on the value of prevention from RWJF.org.

It’s that time of year when public health enthusiasts rejoice and remind the rest of the world why this field is so critical—this is National Public Health Week, a yearly observance since 1995. For 2013, the theme is "Public Health is ROI: Save Lives, Save Money." According to the American Public Health Association, (APHA), a key organizer of the yearly observance, this year’s theme was developed to highlight the value of prevention and the importance of well-supported public health systems in preventing disease, saving lives and curbing health care spending.

In honor of National Public Health Week, NewPublicHealth spoke with Georges C. Benjamin, MD, executive director of the APHA.

NewPublicHealth: Is this the first time that National Public Health Week has focused on the return on investment in public health?

Dr. Benjamin: I think it’s the first time we’ve done so directly. There’s no question that we have always talked about the value of public health and we’ve often talked about savings, but this is the first time we’ve really focused like a laser on that investment.

NPH: What reaction have you seen in states and local communities to this year’s theme?

“Death is an inevitable part of life. But death from preventable causes like cervical cancer, early heart disease, or gun violence is a tragedy. Whether expressed in dry, cold numbers or by the images of first graders smiling at the camera for their school picture, these tragedies will continue to motivate us to use both left-brain science and right-brain passion to improve human health and prevent unnecessary death.”

That paragraph is from the foreword by Michael Klag, MD, MPH, dean of the Johns Hopkins Bloomberg School of Public Health (JHSPH) in the current issue of the school’s magazine. The issue is devoted to how public health researchers and practitioners probe, investigate, understand and fight death.

The full issue is well worth reading. A few notable pieces include: 

• An interview with Vladimir Canuda Romo, PhD, a demographer and assistant professor at the school who says his research shows American life expectancy is on the rise.
• A critical article on making palliative care  a public health issue.
• A summary of a recent forum at the school on dealing with gun violence.
• A piece on prescription drug abuse, which the author calls the “biggest public health issue you’ve never heard of."

Perhaps most poignant are a collection of essays by JHSPH alumni including a thoughtful look at the last minutes of a deer.

>>Bonus Link: In a new book, Happier Endings , Erica Brown, PhD, the scholar in residence at the Jewish Federation of Greater Washington, tells her readers: “we are all going to die, but some of us will die better.” The book, which Dr. Brown calls “a meditation on life and death,” looks at the deaths of several people and shares intimate details of last months, last weeks, last seconds—sometimes peaceful, sometimes not. It’s an important reminder that communities and populations, the building blocks of public health, are made up of individuals who are loved, and missed when they pass away, and that death is indeed a public health issue worth attention.   

U.S. Cesarean Delivery Rates Vary Widely
A new study in the journal Health Affairs finds that the rates of cesarean deliveries, the most common surgery in the United States, vary widely across the country, ranging from 7.1 percent to 69.9 percent of deliveries at close to 600 hospitals studied since 2009. About four million babies are born in the country each year. The study authors also looked at cesarean rates among low risk mothers and found that the variation rate for this group was higher—from 2.4 percent to 36.5 percent. "The variations we uncovered were striking in their magnitude, and were not explained by hospital size, geographic location, or teaching status," said Katy Kozhimannil, an assistant professor at the University of Minnesota’s School of Public Health and the lead researcher of the study. Cesarean rates have increased in the United States from 20.7 percent in 1996 to 32.8 percent in 2011, according to the study. There has been an increased focus on some cesarean deliveries performed before the baby is full term because of the many risks a baby faces when it is born prematurely. Another critical reason to address the issue, say the study authors, is that half of all U.S. births are paid for by the Medicaid program and cesarean births are much more costly than vaginal deliveries. Read more on maternal and infant health.

Chronic Disease Management for Medicaid Beneficiaries Could Lower Health Costs
A recent study of 75,000 women on Medicaid by researchers at the East Tennessee State University found that women with low incomes have a high prevalence of physically disabling conditions and chronic disease. Common chronic diseases included high blood pressure, depression, multiple sclerosis, arthritis, injury, back disorder and Parkinson’s disease. The researchers also found that women who used a mobility device—such as a walker, crutches, or wheelchair—were more likely to suffer from chronic diseases such as diabetes, pulmonary disease, and depression. “These are not women of retirement age. These are rates of chronic disease and disability in a working-age population, so the economic loss to society and the impact on health care costs is substantial," said Amal Khoury, MD, a professor and chair in the department of health services management and policy and the lead author of the study.  "Strategies to improve chronic disease management in the younger adult population may curtail higher disability rates in working-age adults and lower Medicaid and Medicare costs in the long run." Read more on prevention.

Fundraisers at U.S. Schools Too Often Sell Unhealthy Foods
Many public U.S. elementary schools ignore state and district policies banning unhealthy fundraisers, according to a study by researchers at the University of Illinois at Chicago. In the study, principals of 1,215 schools across the United States completed surveys on school food policies for the 2009-11 school years. Overall, only 39 percent of schools had nutritional restrictions on fundraisers, but schools within districts and states with strong policies were more than twice as likely to limit the sale of high-calorie and high-fat foods to raise money. Lindsay Turner, a researcher at the Institute for Health Research and Policy at the university and the lead author of the study, said “[i]t’s hard for schools to give up those financial resources, so that’s why it is essential to have alternative fundraising activities that don’t involve high-calorie products.” Turner ticked off alternatives suggested by the Center for Science in the Public Interest, including walk-a-thons and selling books, greeting cards, fruit, holiday decorations or wrapping paper. “This study puts fundraising on the radar as an issue that needs to be attended to in policy making,” said Turner. “There has been a lot of attention paid to competitive foods and beverages, and this is a really important piece of the entire picture of what’s going on in schools.” Read more on obesity.

Folic Acid Supplements Early in Pregnancy May Reduce Risk of Autism by 40%
Prenatal folic acid supplements appear to reduce the risk for autistic spectrum disorders, according to a study in the Journal of the American Medical Association. The study included more than 85,000 babies born in Norway. Researchers noted prenatal eating habits of the mothers and followed up with families for three to ten years after birth to measure the development of autism spectrum disorders. A total of 270 cases were identified among the children in the study and a review by the researchers found that mothers who took folic acid supplements in early pregnancy had a 40 percent reduced risk of having children with autistic disorders. The researchers say that the timing of a mother’s intake of folic acid appears to be a critical factor. A child’s risk of autism was reduced only when the supplements were taken between 4 weeks before to 8 weeks after the start of pregnancy. Read more on maternal and infant health.

Prescription Drug Abuse Programs in Middle School Reduce Abuse Later in Life
A new study by researchers at the National Institutes of Health (NIH) found that middle school students from small towns and rural communities who were involved in community-based prevention programs were less likely to abuse prescription medications in late adolescence and young adulthood. The study was published in the American Journal of Public Health. According to the NIH, prescription drug abuse is one of the most serious public health problems in the United States.  In 2011, about 1.7 million people ages 12 to 25 abused a prescription drug for the first time, according to the National Survey on Drug Use and Health . “The intervention effects were comparable or even stronger for participants who had started misusing substances prior to the middle school interventions, suggesting that these programs also can be successful in higher-risk groups,” said Richard Spoth, PhD, of the Partnerships in Prevention Science Institute at Iowa State University and the lead author of the study. Those findings contrast with a recent study published by the Substance Abuse and Mental Health Administration that found that 12th grade dropouts have higher rates of cigarette, alcohol and illegal drug use. Read more on addiction.

New Study Shows Significant Health Benefits of Americans Reducing Their Sodium Intake
Hundreds of thousands of lives could be saved over 10 years if Americans reduced their sodium consumption to the levels recommended in federal guidelines, which would prevent many heart attacks and strokes, according to a new study by researchers at UC San Francisco, Harvard Medical School and Simon Fraser University in Canada. The study was published in the journal Hypertension. The study resulted from a workshop conducted by the U.S. Centers for Disease Control and Prevention which brought together scientists from the three universities. Each university group used different computer models to estimate the risk reduction of lowering sodium, but all found consistent, substantial benefits of reducing U.S. sodium consumption to a level close to the upper limit of the federal guideline of 2,300 mg/day.  According to the study, the overall average sodium consumption in the United States has been estimated at 3,500 mg/day, well above the upper limit of the level recommended by federal agencies and the Institute of Medicine. American men consume twice the recommended level on average. Read more on nutrition.

New York Announces Companies Reducing their Sodium Content
Earlier this week, the city of New York announced that  21 companies met one or more of their voluntary commitments to reduce sodium content  in pre-packaged or restaurant foods. Those reductions were the result of the National Salt Reduction Initiative (NSRI), the first-ever nationwide partnership to reduce sodium in the U.S. food supply. The NSRI is a nationwide partnership of more than 90 city and state health authorities and organizations coordinated by New York City since 2009. The NSRI’s goal is to cut excess salt in packaged and restaurant foods by 25 percent over five years through voluntary corporate commitments. Support for the initiative has come from the U.S. Department of Health and Human Services, the Centers for Disease Control and Prevention, the W.K. Kellogg Foundation, the Robert Wood Johnson Foundation, the New York State Health Foundation and the National Association of County & City Health Officials. The project funding is administered by the Fund for Public Health in New York, a private non-profit organization that supports innovative initiatives of the New York City Department of Health and Mental Hygiene. Read more on prevention.