Perhaps my judgment is impaired by the holiday season, but I am optimistic the horrible tragedy of Newtown may present the public with a wonderful gift -- the return of a modicum of introspection, common sense, balance and civility in public discourse.
Many print and broadcast media discussions of the lesson from Newtown exhibit much less polarization, stridency and intransigence than has become the norm.
In my medical specialty of public health, everything can be reduced to a simple equation whereby health status is the product of the interplay of individuals (e.g., genetics, behavior), disease agents and the environment. In the case of Newtown, columnist and psychiatrist Charles Krauthammer recently described the interplay of the killer, the weapon and the cultural climate to produce mass murder. Each of these -- and their interplay -- must be carefully examined -- in lieu of single dimension knee-jerk solutions -- if health status is to improve.
As shocking as the deaths in Newtown are, the personal tragedy is no less in the case of the Lewis County, West Virginia mother who recently shot and burned herself and her two children or the hundreds of children who die from gun violence in Chicago each year.
In the last decade we often have lost our senses of introspection, prioritization and common sense. These begin with an appreciation of the multi-factorial nature of causation and the fact that societal interventions have costs, limitations and consequences -- some intended and some not. It also involves the acceptance of the fact that there is a finite amount of public and private resources that can be directed at health status improvement interventions and priorities must be set.
Over the last few years the country has been assured that heavy public investments in expanded health insurance coverage, integrated care systems and enhanced quality oversights of health practitioners and institutions will produce significant health status gains. As welcomed as these investments may be, they will have a minimal impact on health status. According to the University of Wisconsin analysis, access to -- and quality of -- clinical health services contribute less than 20 percent to health status. An optimistic 10 percent improvement would result in a 2 percent gain.
The country's modest investment in changing the environmental culture regarding tobacco use has produced impressive gains in health behavior and status. Teenage smoking prevalence continues to decline (currently about 10 percent). However, as a more permissive culture has developed regarding the use of cannabis, the teenage use of cannabis has risen in recent years, currently at a plateau. It is expected to continue to rise as, according to recent surveys, far few teenagers view it as dangerous to one's health. Although birth rates have continued to decline, the number of high risk births to single teenagers has shown little decline despite expanded financial access to health services including contraception. Exposure to a culture of violence, substance abuse and permissive sexual behavior is also frequently associated with mental health problems and sub-optimal health status.
Successfully changing cultural norms, e.g., use of tobacco, is a long-term, complex endeavor. In the meantime, we are challenged with identifying and intervening in the case of the highest risk individuals and enticing them to adhere to interventions targeted to reduce their health risk. This involves far more than assuring financial and geographic access to clinical health services.
Proactive identification of those at risk and cajoling/coercing adherence involves population analytical, methodological, communication, legal, ethical, political and social issues we often chose to address only in the abstract, if at all. In the mental health field, recent action to assure parity for insurance coverage of clinical care is a welcome step, but will have a marginal effect on risk identification and adherence. Many diagnosed and insured individuals with serious mental illness are not receiving satisfactory treatment for a variety of reasons.
Where should we concentrate our limited resources if we are serious about impacting health status outcomes? From the tone and substance offered by many who have opined about Newtown, we need to step back and engage in some serious introspection. Hopefully, local communities will develop the structures and mechanisms to do so and be given the authority and resource flexibility to shape effective solutions.
Felsen is a retired public health doctor in Capon Bridge.