Culture of Health Blog

At Virginia Commonwealth University School of Medicine, Briana Mezuk, PhD, is an assistant professor in the Department of Family Medicine and Population Health, Division of Epidemiology; and Tiffany L. Green, PhD, is an assistant professor in the Department of Healthcare Policy and Research. Both are alumnae of the Robert Wood Johnson Foundation (RWJF) Health & Society Scholars program.

Approximately 30 million U.S. adults currently have diabetes, and an additional 86 million have pre-diabetes. The incidence of diabetes has increased substantially over the past 30 years, including among children. Estimates place the direct and indirect costs of diabetes at a staggering $218 billion annually.¹ Like many other diseases, disparities on the basis of race and income are apparent with diabetes. Non-Hispanic blacks, Hispanics, Native Americans, and socioeconomically disadvantaged groups are more likely to develop diabetes than non-Hispanic whites and socioeconomically advantaged groups. 

Despite the enormous economic and social costs associated with diabetes, it remains a struggle to apply what we know about diabetes prevention to communities at the highest risk. We have robust evidence from randomized controlled trials that changing health behaviors, including adopting a healthy diet and regular exercise routine and subsequent weight loss, will significantly lower the risk of diabetes. Unfortunately, these promising findings only appear to apply to the short-term. Even worse, results from community-based translation efforts have been much more modest than expected, and show only limited promise of reducing long-term diabetes risk. In response, leaders at the National Institutes of Health have noted that many efforts at translating clinical findings into community settings are “limited in scope and applicability, underemphasizing the value of context.”²

Amani M. Nuru-Jeter, PhD, is an associate professor of community health and human development, and epidemiology at the University of California, Berkeley School of Public Health, and an alumna of the Robert Wood Johnson Foundation (RWJF) Health & Society Scholars program. Her research focuses on racial health disparities.

Eric Garner’s death and the failure to indict NYPD Officer Daniel Pantaleo have had a profound effect on communities throughout the United States. But it’s not just Eric Garner. This, and similar cases including Michael Brown, Tamir Rice, Trayvon Martin, and Oscar Grant, have put race relations front and center in the national debate.

I’m tired of it, this stops today...every time you see me you want to harass me, you want to stop me...please just leave me alone” –Eric Garner

These last words from Eric Garner are not that different from what we hear in our work with African American women in the San Francisco Bay area:

Chevy Williams, PhD, MPH, is a fellow at Experience Institute, where she is learning and applying design thinking to social problems. Williams is an alumna of the Robert Wood Johnson Foundation (RWJF) Health & Society Scholars program at the University of Pennsylvania. 

Today, we can get access to just about anything in minutes or hours. Smartphones put a world of information literally at our fingertips. Within minutes, most of us can get food we want, entertainment we desire, even travel to another city. But seeing a doctor, an arguably more immediate need, is not so easy. Creating a Culture of Health requires our collective interdisciplinary expertise to make health and health care as accessible and user-friendly as other products and services we use on a regular basis.

Before I left academia, I heard the word “interdisciplinary” tossed around a lot, but I saw it practiced in very safe ways. Typical research teams of grants I was on or would review comprised researchers from only the social, psychological, and health and medical sciences.  As public health faculty, I’d hear statements like “Public health is inherently interdisciplinary.” This may be true since public health draws from multiple disciplines, but I couldn’t help but feel that such statements were more a reflection of inertia than anything else.

Jason M. Fletcher, PhD, is associate professor at the La Follette School of Public Affairs, Department of Sociology, Department of Agricultural and Applied Economics, and Department of Population Health Sciences at the University of Wisconsin-Madison. He is an alumnus of the Robert Wood Johnson Foundation Health & Society Scholars program at Columbia University, where he researched the intersection of health and social networks.

While an important priority for improving health and health care in the United States is in focusing on broad notions, such as creating a Culture of Health, there is also a need to consider targeted approaches that make use of the structure of relationships that influence health. Most people consider only a small number of social contacts when discussing important matters. Even though our Facebook friends number in the hundreds or thousands, the number with whom we share close and regular geographic or social space is considerably smaller. Network science is leading the way in uncovering what our microcultures look like and how they operate; these findings should be put to further use to improve population health.

These “small worlds” of influence are known to have substantial impacts on health—as shown by numerous careful, gold-standard empirical studies. College freshman who are randomly assigned a roommate who binge drinks are more likely to binge drink, themselves. Adults whose spouses stop smoking through a clinical intervention are themselves much more likely to stop smoking. These positive and negative impacts on health spread not through broad culture but through the “microcultures” of close social ties.

Brendan Saloner, PhD, is a Robert Wood Johnson Foundation (RWJF) Health & Society Scholar and an assistant professor at Johns Hopkins University. On this first Universal Coverage Day, Saloner examines holes in access to care that remain after the Affordable Care Act. His post is cross-posted with the Leonard Davis Institute of Health Economics blog.

The United States is the last remaining rich country in the world where a large percentage of the population lacks health insurance coverage. This situation is being improved under the Affordable Care Act (ACA), with recent estimates showing that from early 2013 to mid-2014 the uninsured rate dropped from 19 percent of adults to 14 percent. The uninsured rate will no doubt continue to fall in 2015, but the problem of the uninsured will not go away with the ACA. It will not go away even if all 50 states expand Medicaid for poor adults, and will not go away if the U.S. Supreme Court rules against the plaintiffs in a pending challenge to the power of the administration to provide subsidies in the federally facilitated insurance exchanges.

In its 2012 baseline estimate, the Congressional Budget Office (CBO) projected that by 2022 the ACA might cut the number of uninsured by half, but would still leave behind 30 million people without insurance. This projection assumed full implementation of the ACA provisions. We don’t yet have a clear sense of how much larger that number will be with incomplete implementation of the core ACA coverage provisions, but even an optimistic assessment is that tens of millions of Americans will continue to spend periods of time without health insurance.

Who does the ACA leave behind? By design, the ACA excludes undocumented immigrants, a group that numbers around 11 million today. Some undocumented immigrants purchase private insurance, receive coverage from an employer, or participate in public programs funded with non-federal dollars, but the majority have no insurance. Undocumented immigrants are prohibited from enrolling in Medicaid, receiving subsidies, and purchasing coverage on the exchanges. Although President Obama recently signed an executive order protecting many undocumented immigrants from immediate deportation, the ACA exclusion will continue in the foreseeable future, barring an act of Congress. 

Jennifer Schroeder, Stephanie M. DeLong, Shannon Heintz, Maya Nadimpalli, Jennifer Yourkavitch, and Allison Aiello, PhD, MS, professor at the Gillings School of Global Public Health, University of North Carolina at Chapel Hill and an alumna of the Robert Wood Johnson Foundation (RWJF) Health & Society Scholars program. This blog was developed under the guidance of Aiello’s social epidemiology seminar course.

Ebola is an infectious disease that the world has seen before in more moderate outbreaks in Africa. As the devastating Ebola outbreak in West Africa has taken a global turn, fear, misinformation and long-standing stigma and discrimination have acted as major contributors to the epidemic and response. Stigma is a mark upon someone, whether visible or invisible, that society judgmentally acts upon. Ebola has become a significant source of stigma among West Africans and the Western world.

In many ways, the source of this discrimination can be traced back to the legacy of colonialism and the western approach to infectious disease response in Africa. The history of foreign humanitarian aid has sometimes dismissed cultural traditions and beliefs. As a consequence, trust in westerners has eroded and has been compounded by a disconnect between western humanitarian aid approaches and a lack of overall infrastructure investment on the part of African national health systems. This is apparent in the Ebola epidemic in West Africa. Some don’t actually think that Ebola exists; instead they believe that it is a hoax carried out by the Western world. All of these factors are facilitating the rapid spread of the disease.

By Sheree Crute

Maricelle Ramirez is a foot soldier in America’s battle against obesity. For three years, Ramirez has politely offered Boston area patrons of McDonald’s, Kentucky Fried Chicken, Burger King, Dunkin’ Donuts, Wendy’s and Subway a $2 gift card in exchange for their estimates of the amount of calories in their fast-food feasts.

“I’ve met all types of people,” Ramirez says, recalling the surprise of encountering a nutritionist who was on her way out of McDonald’s after chowing down on a burger and fries. “She explained that she was just enjoying a meal because she had a craving for something indulgent, but she provided a very careful nutritional analysis of what she was eating.”

At the other end of the spectrum was an older woman leaving Kentucky Fried Chicken with a drumsticks-to-mashed potatoes spread for her family who confessed, “I don’t know much about the calorie content of the food, but it would really make a difference for me and my family if I had more information.”

Sara Shostak, PhD, MPH, is an associate professor of sociology at Brandeis University and author of Exposed Science: Genes, the Environment, and the Politics of Population Health. She is an alumna of the Robert Wood Johnson Foundation (RWJF) Health & Society Scholars program (2004-2006). 

Human Capital Blog: Your book, Exposed Science, won two awards from the American Sociological Association: the Eliot Freidson Outstanding Publication Award from the Medical Sociology Section and the Robert K. Merton Book Award from the section on Science, Knowledge, and Technology (SKAT). Congratulations! What do these awards mean for you and your work?

Sara Shostak: Thank you! I am deeply honored that Exposed Science won those awards. This kind of recognition from one’s colleagues is tremendously meaningful on a personal level, especially as there are many scholars in these sections whose work has inspired me for years.  

More broadly, the dual awards signal something important about the connection between these two domains of inquiry—medical sociology and the sociology of science. That is, science and the politics of science are important foci of analysis for sociologists concerned with population health. The conditions under which scientists do their research—the political economy of knowledge production—is a critical context for what we do and do not know about human health and illness.  

Population health researchers often observe that in the United States, health disparities research tends to focus on differences between racial and ethnic groups, while in the United Kingdom the focus tends to be on variations by social class (or what U.S. researchers more often call socioeconomic status). Scholars of science, knowledge, and technology can help us understand how and why these differences emerged, and with what consequences. My book raises questions also about how any of these determinants get operationalized in laboratory-based research. All of these aspects of how science is done have direct implications for public policy, as well.

Sonya Grier, PhD, MBA, is an associate professor of marketing at the Kogod School of Business at American University in Washington, D.C., and an alumna of the Robert Wood Johnson Foundation (RWJF) Health & Society Scholars program (2003-2005).

Human Capital Blog: Congratulations on receiving the Thomas C. Kinnear award for your 2011 article in the Journal of Public Policy & Marketing on food well-being! Please tell us about the award.

Sonya Grier: The award honors articles published in the Journal of Public Policy & Marketing (JPP&M) that have made a significant contribution to the understanding of marketing and public policy issues. This year, eligible articles needed to have been published between 2010 and 2012. The marketing community was called upon to nominate articles for the award. JPP&M editorial review board members and associate editors then voted among the nominees.

Generously funded by Thomas C. Kinnear, his colleagues, friends and former students, and administered through the American Marketing Association  Foundation, the award’s purpose is to recognize authors who have produced particularly high-quality and impactful research in marketing and public policy.

HCB: How did your article do that?

Elizabeth Sweet, PhD, is a biocultural anthropologist researching economic and racial disparities in health and an alumna of the Robert Wood Johnson Foundation (RWJF) Health & Society Scholars program (2008-2010). She was the lead author of a recent study exploring the impact of financial debt on health. 

Human Capital Blog: You have published more than one study that looks at the impact of debt on health. What led to your interest in this topic?

Elizabeth Sweet: My interest is driven by both intellectual and personal reasons. As someone who studies the impact of social inequalities on health, I am interested in personal debt as a dimension of socioeconomic status, a site of racial and economic disparity, and a reflection of broader social, cultural, and political-economic forces. Also, as someone who completed education with a fair amount of debt, I am personally familiar with the profound stress that debt can cause.

HCB: College tuition is rising and more people are defaulting on student loan debt. How does student loan debt affect young people’s mental and physical health?

Sweet: This is such an important question. Our study suggests that financial debt indeed impacts the health and well-being of young people—leading to higher stress and depressive symptoms, worse general health, and higher blood pressure. The specific impact of student loan debt, vs. other kinds of debt, is an open question though; the Add Health data that we used did not have that level of detail regarding the types of debt that respondents had.