What Can “Chronic Resilience” Teach Public Health Practitioners? An Interview With Author Danea Horn

Last month I had the pleasure of receiving an advanced review copy of "Chronic Resilience: 10 Sanity-Saving Strategies for Women Coping with the Stress of Illness".  As I read through the book, I made note of many issues that are relevant to public health practitioners.  Therefore, it is a pleasure to have Danea Horn expand her comments on these topics for Pop Health readers. 

If you would like to connect with Danea, you can visit her website or twitter.

Leah:  In public health, we talk a lot about how our society’s “culture” can promote or harm health.  In several places in your book, you talk about the connection between our societal values and our health.  For example:

Page 33: “Part of the reason we try to be all things to all people is our culture.  Have you ever sat through a business meeting while someone is sniffling and sneezing and exposing everyone else to their cold?  In that moment they are valuing achievement, money, or appearances above their health and the health of everyone else in the room.”

How can we expand your strategies beyond the individual level?  How can we identify and live our health values at the neighborhood, community, and organization levels?

Danea:  It only takes one person to start a conversation that can become the catalyst for big changes. Start talking to people at your work and in your community to get a feel for what is valued currently. The policies (written and unwritten) in our offices and items at our potlucks will say a lot about what we collectively value. If you find inconsistency or confusion in your conversations, open up a dialogue with the leaders in your organization or community to discuss what you would like to collectively choose to value. From here you can brainstorm together ways to influence change. They can be small changes like creating a healthy living block party where people share nourishing dishes and swap good-for-you recipes or larger changes like paid sick leave (which is not mandatory in every state…yet). Never be afraid to speak up. A big theme in Chronic Resilience is controlling what you can control and talking is in your control. 

Leah:  In Chapter #6, you write “It is up to you to decide how public to make your health.”  You and several of the women you interviewed for your book have blogs that document your health journey in a very public way.  Public health researchers Ressler et al (2012) have identified many benefits of patient blogging (e.g., patients report a decrease in feelings of isolation).

What benefits have you experienced as a result of writing about your health?  What challenges have you encountered during the process of sharing your story publicly?

Danea:  Writing helps me process what is going on from a different perspective. I am all about learning from our challenges, so each post I write is a search for a lesson or message that my diagnosis is pointing me toward. I can feel frustrated about the progression of my disease and start out writing a rant, but I find that I naturally end up with a message about letting go of my ideals or acceptance. Reframing my health in this way has been very empowering.

I haven’t encountered many challenges by being public with my health journey. Commenters have been very supportive. That said, I am discerning about what I choose to share and do keep some things private. Challenges I know other people have faced, and someone who blogs publicly about their health should be prepared for, are people sharing remedies, treatment recommendations, cure-all solutions and pleas to have faith in a deity they may or may not believe in. While these all come from a caring place they may feel intrusive. Also, you may want to give a heads-up to your close family and friends before you post anything particularly revealing, emotionally or otherwise, that you haven’t shared with them in private first.

There are a number of ways to benefit from writing about your health. Doing it publicly on a blog can create a sense of support and community, but if that feels too invasive, you can join support forums anonymously, create a private blog or journal pen and paper old school style.

Leah:  In Chapter #7 (“Empower Yourself With Research”), I was thrilled to see your emphasis on helping patients evaluate the validity and safety of medical information found on the Internet.  This is a huge challenge in public health!  Our evidence-based messages and guidelines often compete online with anecdotal evidence and unscientific studies.

Why did you decide to dedicate a portion of your book to this discussion?  Why is it so important for patients to discuss what they find online with their medical team?

Danea:  Before I became discerning about what I read online about my diagnosis, I was completely stressed. I read way too much from too many random sources to properly sort out what I should believe. I also noticed that I was searching for how I was going to become sicker (the side effects, complications, and progression of my illness) instead of searching for how I could support my heath. Fortunately, I realized most of my stress was coming from worry created by endless Internet searching, and I decided to take a different approach.

I found a few sources from trusted physicians and nutritionists to study and implement. I decided to stay focused on my personal symptoms, medications and prognosis instead of what other people I didn't even personally know had experienced. I also started a more open dialogue with my doctors about the diet I wanted to try and some of the studies I had read. When we research and experiment with our health without informing our doctors, we may have conflicting approaches which can create drug interactions or other harmful complications. Doctors are there to support us. If you are uncomfortable talking with yours, it’s time to find one that you trust enough to be completely open and honest with. We should all have a doctor who will work with us to find treatment solutions we feel comfortable with.

Leah:  A big thank-you to Danea for making the time for Pop Health!  "Chronic Resilience" is a great read for those with a personal and/or professional connection to chronic illness.  For public health clinicians, practitioners, and researchers who work in the chronic illness arena:  I think you will get a unique first-hand view into (1) the mental, physical, and emotional challenges that affect this population, (2) the incredible resilience that those with chronic illness show on a day-to-day basis (what can we learn from them??), and (3) specific strategies that can be employed to support patients with chronic illness.  As Danea and I discuss above, these strategies have the potential to be expanded from the individual level to offer support to entire communities.

Pop Health Hits 100! Revisiting 5 Favorite Posts.

In honor of Pop Health hitting the milestone of 100 posts, I wanted to take the time to look back, thank my readers (face to face!), and revisit some of my favorite posts.  I selected posts that (1) generated the most readers, (2) solicited the most comments, (3) connected me with colleagues, and/or (4) were just really fun to write and promote!

I am also celebrating this milestone with my first video post!


1.  "Bullying: Is Technology Helping Us Or Hurting Us?"  [October 5, 2010)

2. "Friends Don't Let Friends Drive Drunk:  How Soon Is Too Soon To Find The Teachable Moment In The Death Of Ryan Dunn?" [June 23, 2011]

3.  "Facebook Adds Organ Donation To Timeline: Should We Like It?"  [May 1, 2012]

4.  "Angelina Jolie's "Medical Choice" Dominates The Internet"  [May 14, 2013]

5.  "How And Why Should We "Pin" Public Health?" [June 18, 2013]

Do Celebrities and the Media Combat or Perpetuate Stigma Around Breastfeeding?

This week's guest post was written by Jennifer Breaux, DrPH, MPH, CHES.  She is an Assistant Teaching Professor & Director, Undergraduate Education at the Drexel University School of Public Health.  Her work is focused on maternal & child health, nutrition, and health as a human right.

Over the past month, Alicia Silverstone has entered the public health conversation once again by launching a vegan mother breast milk sharing program through her website The Kind Life.  The program has been featured by several national media outlets.  Although her idea of milk sharing is not a new one, it has reignited arguments and opinions on both sides.  For example, US Weekly ran a short piece about the proposed milk sharing program where it provided the information but did not give an opinion.  Unfortunately, many uneducated and harsh opinions were given in the comments section of this piece.  They ranged from stating that this was a horrible idea that would give babies diseases to questioning why someone would choose to give breast milk in this situation when there is formula.

I felt compelled to write this blog post because issues relating to breastfeeding and breastfeeding policies are extremely near and dear to me both personally and professionally.  The issue is also quite timely considering that August 1-7 is World Breastfeeding Week and the month of August is Breastfeeding Awareness Month.

Combating Stigma
Alicia’s program was first reported on by Good Morning America (GMA) and I was struck by the uncomfortable nature of the anchors when the health reporter presented breast milk on the table.  Seeing the breast milk out in the open resulted in a visceral reaction of unease for some of the hosts.  I was happy to see the reporter debunk some milk sharing myths like (1) the milk is unsafe, (2) it transmits disease and (3) it is an unnecessary service.  Overall, I thought that GMA did a balanced job of reporting the story.

Perpetuating Stigma
While stories like that on GMA  (in which a medical professional reinforced the safety of breast milk sharing) can help combat stigma, stories like the one in Life & Style can perpetuate it.  The Life & Style magazine ran a story with a quotation by TV host Wendy Williams who basically equated milk sharing with slave nurses and the Civil War.  

The roots of milk sharing date back to wet nursing and this practice actually dates back to before Christ and has been practiced through the centuries.  Yes, wet nursing did exist during times of slavery but it is also something that still exists today – largely invisible to the general population.  However, it did make main stream news outlets a few years ago when Salma Hayek breastfed a malnourished infant during a humanitarian trip to Sierra Leone.    The whole concept of wet nursing and milk sharing is not new and truly a selfless act that has become a life saving option for mothers who can’t or choose not to breastfeed.

The Facts About Safety
The Human Milk Banking Association of North America (HMBANA) was established in 1985 and remains the largest group to acquire breast milk.  It is a lifesaving organization for premature and ill infants and has locations across the country.  One of the main arguments against something like milk sharing is the spread of disease.  Milk that is obtained for the HMBANA meets rigorous standards.  Milk donors are screened and once the milk arrives at the bank it is:

• Pasteurized to eliminate harmful bacteria,
• Lab tested to make sure the milk is safe and free of any communicable diseases that are able to be spread in milk, and
• Once it is ruled free of any cultures, the milk is able to be shipped to recipients

These standards enable parents to give donated milk knowing that it is safe and what is best for their infant.

That being said, there are informal milk sharing programs that are not regulated; the milk does not go through the rigorous testing done by HMBANA, which could pose a public health risk for those receiving the milk.  However, those who choose to participate in these networks are aware of the risks and feel that the benefits provided by breast milk outweigh possible consequences because the amount of external substances absorbed in breast milk is quite small.   An additional reason that families may choose this alternative route is cost.  Babies drink A LOT of milk and to get certified milk from HMBANA for the first year of life is extremely expensive and is only covered by insurance under certain circumstances.

A Call To Action
We, as a society, have opinions on these types of breastfeeding programs, but the debate will continue until we deal with the root cause of the need for increased milk sharing - our poor breastfeeding rates.  According to the World Health Organization and the American Academy of Pediatrics, it is recommended that mothers exclusively breastfeed their infant for the first 6 months of life followed by breastfeeding, in combination with the introduction of complementary foods, until at least 12 months of age and continuation of breastfeeding for as long as mutually desired by mother and baby.  In 2012, the national breastfeeding rate of exclusive breastfeeding at 6 months was only 16.3% with certain subgroups falling far below this percentage.

Stigma surrounding breastfeeding and the lack of support on every level will continue to plague this issue. The irony is that the science is clear – breastfeeding has overwhelming positive benefits for the baby, mother and society.

Some of the proven positive health benefits for breastfed babies are reductions in/of:

• Hospitalization from lower respiratory infections
• Ear infections
• Serious colds, ear and throat infections
• Necrotizing entercolitis
• Sudden Infant Death Syndrome (SIDS)- after accounting for confounders
• Allergic disease
• Celiac disease
• Irritable Bowel Syndrome (IBS)
• Obesity
• Type I Diabetes
• Childhood Leukemia and Lymphoma

Some of the proven health benefits for the mother (time dependent) of breastfeeding:

• Decreased postpartum blood loss
• More rapid involution of the uterus (post childbirth)
• Increased child spacing (lactational amenorrhea)
• Possible decrease in postpartum depression
• Decreased risk of Type 2 Diabetes
• Inverse between breastfeeding and rheumatoid arthritis
• Reduction in hypertension, Cardiovascular Disease (CVD)
• Reduction in breast and ovarian cancer
• Reduction in osteoporosis

Additional benefits from breastfeeding annually:

• $13 million in direct health care savings
• Prevention of at least 5,000 cases of breast cancer
• Prevention of at least 54,000 cases of hypertension
• Prevention of at least 14,000 heart attacks
• Prevention of the three outcomes above result in about $860 Million in health care savings

Breastfeeding is good public health.  Maybe we should start investing more in making sure babies are able to be breastfed and, if not- afford them the ability to receive affordable and safe breast milk.  We MUST stop considering breastfeeding as a woman’s lifestyle choice and view it for what it really is:  an important health issue, a public health issue and a human right.

HBO Presents "The Crash Reel": Examining The Enormous Impact Of Traumatic Brain Injury (TBI)

Traumatic Brain Injury (TBI) is a public health problem.  We hear about it a lot in relation to the members of our Armed Forces.  In fact, TBI has been "one of the signature injuries of troops in Afghanistan and Iraq".  There has also been much discussion in the media (and here on Pop Health) about the impact of TBI on National Football League (NFL) players.

On July 15, 2013 HBO premiered an incredible documentary called "The Crash Reel".  This film follows U.S. snowboarder Kevin Pearce as he rises through the ranks of the sport, dominates international competition in the run-up to the 2010 Olympics, survives a horrific training accident in Park City, Utah and launches a come-back to his life (and possibly) the sport he loves so much.

The documentary does an amazing job of examining both macro and micro public health issues as they relate to TBI.

Society:

During a poignant interview, Kevin's Dad says "we were all to blame" [for Kevin's injury].  The spectators, the families, the sponsors....he believes they all have a role in injury prevention and athlete safety. He asks why the halfpipe walls keep getting higher and higher (increasing speed, height, and risk of the tricks).

Risk culture and the role of spectators and sponsors in perpetuating this culture is called out in "Wrecks Over Reason", an article running in the August 5, 2013 issue of Sports Illustrated (SI).  Referencing the "X Games" specifically, athletes acknowledge that the audience is hoping to see crashes.  The author Austin Murphy writes, "Indeed, many of the events-at the X Games in particular and in the extreme sports world in general-seem designed to ensure a modicum of carnage.  That's what people are tuning in to see".  

Family and Friends:

Kevin's close-knit family is a big part of the documentary.  We hear them recount how they learned of his accident and through pictures and video, we see them assume the role of caretakers.  It is clear that TBI can have an enormous impact on a person's entire family.  His brother Adam quits his job to help Kevin through his rehabilitation.  His mother is by his side for almost every appointment.  His roommate helps to counter his memory loss by helping with organization and medication.

Having almost lost him and with their lives heavily impacted during his recovery, their fear is understandable when Kevin talks about getting back to snowboarding.   Although his physicians and family constantly reinforce the danger that a second head injury could bring (i.e., it could be fatal), Kevin is determined to return to the sport.  

Kevin:

The accident was caught on video and is horrific to watch. All things considered, Kevin makes a pretty amazing recovery.  He spends 3 months in the hospital and then participates in ongoing rehabilitation to address the lingering effects of his injury: double vision, impulse control problems, memory loss, and depression.  He wrestles with accepting that his injury is life-long and will forever change the trajectory of his life and career.

According to the Centers for Disease Control and Prevention (CDC), at least 1.7 million TBIs occur every year, either as an isolated injury or along with other injuries.  The costs of these injuries are huge- not just in terms of medical costs, but in terms of lost productivity for that individual (and their friends/family that serve as caretakers).  While it is important to focus on helmet use and other individual-level interventions, I applaud the tone of this documentary and the SI article above.  I hope they ignite a discussion of society-level (and sports-level) interventions for traumatic brain injury. 

#RoyalBaby Offers Public Health A Unique Opportunity To Advocate For Maternal and Child Health

As Catherine, Duchess of Cambridge, went into labor early yesterday morning, public health organizations and advocates took advantage of the opportunity to talk about maternal and child health.  Since much of the world was following the #RoyalBaby story, it made sense to make the connection to public health work.

Here are some of my favorite tweets and topics:

VACCINATIONS

 

 NEWBORN SCREENING

BREASTFEEDING

Andy's tweet was in response to this image from Oreo:

PRENATAL SMOKING

SUPPORT FOR NEW PARENTS

As I've noted in related posts, I hope these organizations are evaluating their communication strategies!

• Have they seen an increase in traffic to their websites and resources?
• Have they engaged a new audience by aligning with the #RoyalBaby news?
• What organizational resources are needed to develop communication plans that coordinate with timely global and pop culture news?
• What lessons learned can be applied to future communication efforts? 

What do you think?

• Are these types of communication strategies effective in reaching a broader audience?
• Are there other relevant public health tweets that you felt were creative and engaging?  Please share!!

Everything I Need To Know About Public Health Preparedness, I Learned From "Sharknado"

If you were on twitter last night, you might have witnessed the phenomenon that was "Sharknado".  You take a corny Syfy disaster movie, add in Tara Reid and Ian Ziering (of 90's fame in "American Pie" and "Beverly Hills, 90210" respectively) and it becomes something great!

In the midst of a rare California hurricane, super tornadoes suck up sharks from the ocean and hurl them around the Los Angeles area.  There is flooding, wind, debris, and sharks swimming in the streets.

While the movie was outrageous (as expected), this tweet from the Red Cross got me thinking about its surprisingly relevant public health preparedness messages:

#1:  Always Be Prepared  
Over and over, the lead character Fin (Ian Ziering) tells his kids "Semper Paratus".  That is Latin for "always prepared".  That is the key to preparedness- as evidenced by FEMA's slogan on Ready.gov- "Prepare. Plan. Stay Informed".

#2:  Prepare For The Unexpected
Los Angeles is more well known for its earthquakes than its hurricanes.  In fact, the article "Is there science behind 'Sharknado'?", tells us that a hurricane has never hit Los Angeles and we must go back to 1858 to find a hurricane that hit southern California.  However, just because your town has never had a historic hurricane, tornado, or fire does not mean you should not prepare for one.  Everyone should have an emergency plan in place.  You never know!

#3:  Evacuate And Get To Higher Ground
After waves and flying sharks shattered the windows of Fin's beach bar in Santa Monica, they hightailed it out of there and drove to higher ground!  My only critique is that they drove through some very flooded streets.  Remember, "Turn Around, Don't Drown" is a National Weather Service campaign to warn people about the dangers of walking or driving a vehicle through flood waters.

#4:  Check On Friends And Family
Although April (Tara Reid) demanded that her ex-husband Fin leave her alone and that the storm was "just a little rain", he came anyway.  And good thing that he did!  Otherwise, she and daughter Claudia may have been eaten by the shark swimming in their pool or crushed when their house collapsed in the flooding.

#5:  Shop For The Emergency Supply Kit Essentials
While FEMA offers a great list of kit essentials, it was fun to watch the Sharknado crew add a few more creative items like chainsaws and bombs.  Whether or not you saw the movie, I highly recommend that you check out this GIF of Fin, a shark, and a chainsaw.

Tell Me What You Think:

• What was your favorite scene from Sharknado?
• What other public health preparedness lessons did you learn?

Pinning Public Health: A Spotlight on Hamilton County Public Health

On June 18, 2013 "How and Why Should We Pin Public Health?" became one of Pop Health's most popular blog posts.  So you can imagine my excitement to share a follow-up piece that spotlights the Pinterest work at the Hamilton County, Ohio Public Health Department! 

Today's post is written by Christy Cauley, M.Ed., an Electronic Communications Specialist, who is responsible for the department's social media strategy.  Hamilton County Public Health (HamCoHealth) was established in 1919 to serve more than 460,000 Hamilton County residents living outside the cities of Cincinnati, Norwood, Sharonville and Springdale. With a staff of more than 80, including sanitarians, plumbers, health educators, nurses and epidemiologists, Hamilton County Public Health strives to prevent disease and injury, promote wellness, and protect people from environmental hazards.  

I am very fortunate to work for a local public health department that understands the value of a strong social media presence. Hamilton County Public Health  has a strong presence on Facebook, Twitter and YouTube and now we’re expanding our presence on Google+ and Pinterest. The latter’s image-centered format poses many challenges to public health entities. After all, who wants to look at pictures of syphilis?

That simply means we have to get creative. Rather than pinning a picture of syphilis, I’ll pin a picture of a cute stuffed amoeba that represents syphilis. The photo still links to an article that lets everyone know there is a syphilis epidemic in Cincinnati and what they can do about it, but they are spared the sometimes graphic images that are associated with public health.

We also have to consider our audience. Our Pinterest audience is quite different from other social media outlets. For starters, there is a much stronger female presence on Pinterest. In fact, the vast majority of our followers are women. That affects our pins and our boards – we have a Women’s Health board for example. Our pins have much more to do with family health and safety than our other social media pages. We tend to focus on health, nutrition and fitness, things that matter more to women than men. We have many pins on Pinterest that do not make it to our Facebook or Google+ pages because the audience just isn’t right for it.

Growing our audience has been challenging on Pinterest. Few people outside the profession are really interested in public health until there is a reason to be interested – like an outbreak of West Nile Virus, for example. We take the usual steps – following others’ boards, liking, commenting and repinning when possible. But what we really want is interaction with our stakeholders on our own boards. We want to get our messages out and know that our audience is hearing them.

To help with that goal, we have “public” boards where we allow others to post to our boards (and we have been invited to do the same). This creates boards with people of similar interests who can share pins more easily. We are careful to include a disclaimer on these boards however, and we do monitor outside pins. Our public health and safety boards can only be pinned on by us, but our recipe and fitness boards are open for our followers to share their favorite pins and they do. We pin to a public board called Health Communication & Social Media from Raed Mansour, where social media and communications professionals can share their ideas. Before, our only interaction with these professionals was on Twitter.

Interestingly enough, the place where we receive the most interaction on Pinterest is one of the public boards we were invited to pin to – Cat World, a board by Joyce Egoodman. Yep, you read that right, Cat World. What does that have to do with public health, you ask? Not a lot, although we can connect pets to our emergency preparedness and heat safety topics quite easily. But, people who love cats are our stakeholders. Public health affects everyone, even our pets. And who doesn’t like cute cat pictures?

How it works is we will find the cutest cat picture on our following boards in the morning and repin it to Cat World with a message about public health or safety. That pin then gets repinned by anyone who likes the picture – not necessarily the message. In turn, our message gets disseminated all over Pinterest and it only took a few seconds of our time. Our Cat World pins get commented on, liked and repinned much more often than our other pins because that board has a wider audience (for now).

One of the Social Media for Public Health (#SM4PH) Twitter chat participants (@AmandaMPH) mentioned that there is a LOT of unhealthy dieting information on Pinterest and we have also found that to be the case. That’s one of the reasons it’s so important for health departments to have a presence on Pinterest, so we can put out accurate information that people can trust.

We’ve found that the image is as important as the message. As a result, we keep our messages short and sweet and we keep our pictures creative. For example, did you know Ryan Gosling is the poster boy for public health? There are hundreds, maybe even thousands of Ryan Gosling memes and many of them are public health centered. We try to utilize them on “Fun Friday” as much as possible.

Another small thing we do is change our board covers often. When new stakeholders visit our page, we want them to see a captivating image that makes them want to view the board, but we also want to make sure that the pin in question is toward the top of the board. I can’t tell you how many pages I’ve visited where I wanted to repin the board cover image, but once I clicked the board, it went on forever and the cover photo was nowhere to be found. We want our stakeholders to find things easily. It’s a small thing, but don’t underestimate its importance to the aesthetics of your page. And don’t neglect the description and category areas either.

We have also taken advantage of @PinGraphy, which allows us to schedule pins for certain times and days. When interaction matters so much and we do not have someone on social media on the weekends, this tool is invaluable. (We use HootSuite for scheduling our other social media sites.)

Getting our feet wet in Pinterest has been challenging. We have made a lot of changes to our boards since we started in response to feedback from users. We’re still learning, but we hope that Pinterest will be a valuable tool in spreading our messages about public health and safety issues in Hamilton County, Ohio and throughout the world.

A Pop Health Book Review of “My Foreign Cities: A Memoir”

I cannot remember the last time I was so engrossed in a book that I looked up with shock to see the clock read 2:00am.  Well, that happened to me on both Friday night (when I started) and Saturday night (when I finished) the book “My Foreign Cities”.  The memoir chronicles the love story between author Elizabeth Scarboro and Stephen Evans.  In late high school/early college, their friendship grew into love and Elizabeth chose to be with Stephen, even though she knew his cystic fibrosis (CF) would limit his life expectancy (30 years old on average), impact her choices, and reduce their time together:

"In comparison to Stephen, most things would be there.  If I wanted him, I had to hurry up" (page 36).

While there were numerous public health topics of interest in this book, I was most struck by the strength, resilience, and creativity that Elizabeth brought to her role as a caregiver.  While the focus was on Stephen's health, we also learned how and when she needed to take care of herself.  Many of her words have stayed with me, so I'm weaving her eloquent quotes into this review.

Throughout the book, I was surprised by how she could both focus on the present and think about her future.  Even though she knew that future would not include Stephen at some point:

"Back then, this was my plan to get through Stephen's death: I'd have a life, a self, I wanted to continue after he was gone.  But I couldn't invent that on the spot- it would have to already be there, which meant I'd need to live it while he was here too" (page 79).

Because of this mindset, the reader gets to hear about the risks and adventures they took- both big and small.  The big being the trips to Mexico, Hawaii, Scotland, and Ireland- the moves to San Francisco, Boston, and back to San Francisco again- going to graduate school- and getting married.  The small being the clandestine escapes to the hospital roof for privacy during a long stay and their wonderful hikes around their homes in Denver and San Francisco.  Elizabeth's writing is so vivid that you can see the scenery, feel the air on your face, and sometimes hear Stephen's labored breathing.

When Stephen struggles with a dangerous addiction to his pain medication, we are reminded that caregivers deal with all the side effects and dangers that surround an illness- not just the disease itself.  Stephen managed to hide the addiction from Elizabeth for almost a year.  Their relationship and communication were challenged as she tried various solutions to the problem- locking up the medications, alerting his physicians. Elizabeth talks about how his withdrawal symptoms and subtle disclosures were often lost on her because she always viewed things within the larger context of CF:

"But that was the great thing, and the dangerous thing, about life-threatening illness- every other problem appeared like a sideshow when cast in its light" (page 108).

When Elizabeth battles depression during Stephen's recovery from a double lung transplant, we are reminded that caregivers have their limits and that self-care is incredibly important:

"And then I crashed.  Not in the way that Stephen might have, with none of the magnitude or danger, but in the way of a healthy person, slipping slowly, with the strong sense that it couldn't be happening, I could fix it if I just tried hard enough.  Maybe I crashed because I finally could, because Stephen was okay" (page 188).

During her recovery from depression and later- as Stephen's condition worsens, the reader is introduced to Elizabeth's amazing support network.  I can only hope that every caregiver has a group of friends/family like hers:

"Back home, my friends converged to take care of me, like incredibly skilled dancers, hiding the work of it, moving so seamlessly that I barely noticed the details, I just felt, underneath me, a solid floor" (page 273).

I would highly recommend this book to public health professionals, clinicians, patients, and caregivers.  While some parts are heartbreaking, the theme of resilience dominates.  We also get an inside view to patients and caregivers that should help us think about access to health care, quality of life, and the empowerment of patients.

I would also recommend this book because Stephen was one of us.  After college, he enrolled at the Harvard School of Public Health to pursue his interest in health care policy:

"Stephen was most concerned about how people without insurance would be managed, or worse, not taken into account at all.  He felt indebted to the California state system that covered CF, and he wanted to give back" (page 103).

I hope this book helps continue this legacy for Stephen.  I hope the book ignites conversation about access to care, coverage for the uninsured, and support for chronic illness patients, transplant patients, and their families.

Supplemental Information:

• My Foreign Cities: A Memoir- Facebook Page
• Pew Internet & American Life Project- New data on caregivers and how they use technology to find health information

Instagram It! Using Instagram for Public Health

This week's guest post for Pop Health was written by Alyssa Anderson.  She is a Community Health Education graduate student focusing on health promotion and work site wellness. Originally, she thought employee wellness was her niche but soon discovered that social media took 1st place in her heart. Finding ways to weave health promotion, marketing, and communication with social media is her main focus these days. She currently lives on Pensacola Beach, FL, enjoying her slice of paradise on the Gulf Coast. 

Follow Alyssa on Twitter, Instagram, and pin with her here!

There is certainly a wide range of social media channels discussed on Pop Health. However, as I was browsing and chatting with Leah about this guest post, we discovered that Instagram had not yet been covered. I jumped at the opportunity to highlight some public health organizations using this channel. And with the revealing of Instagram Video, the timing just seemed perfect.

A quick search of Instagram revealed that a number of public health organizations are actively using this photo-sharing application.

• Chicago Department of Public Health (By the way, congratulations to the Blackhawks!)
• American Public Health Association
• Austin, TX Department of Health and Human Services (what they did is really great, more to come!)
• The Red Pump Project (Hey, National HIV Testing Day is June 27!)
• American Cancer Society
• The list continues…

While there are quite a few public health organizations on Instagram, their usage differs. For example, Chicago Department of Public Health is sharing mostly promotional messages, such as

It may seem simple and a no-brainer, but these posts have received little engagement. A "like" here, a comment there, but no real involvement from other followers.  In fact, Chicago Department of Public Health only has 195 followers. In a city of 2.7 million, their Instagram is having very little reach.

On the other hand, the Red Pump Project has 905 followers. They promote awareness and education for women and girls about HIV/AIDS using the red shoe as their symbol. Users can tag their pictures with #RockTheRedPump to show their support. Typical posts are from events, putting faces to their movement, and event promotion. Here are a few snapshots:

The images are more colorful and vibrant than those posted by the Chicago Department of Public Health. And some image descriptions have a call to action…asking followers to like and share, comment below, etc. The second picture has 47 likes and most have over 20 likes with comments.

On social media, using calls to action or cues inspires people to do just that. Regardless of the message or reason for using social media, engaging with your target audience is key and helps to expand your reach.

Now, the city of Austin tried something this past April during National Public Health Week. They tasked their audience, the citizens in the city to help them answer a question: What is public health? Instagram users were to snap a picture of what public health means to them in Austin with the unique tag #austinpublichealth.

Such a great idea! Think about it, a photo journey from your target audience about what public health means to them. You could almost use these as unfocused focus groups and see what your audience does with the resources you have provided.

Unfortunately, only 17 pictures were tagged with #austinpublichealth. Bummer.
Here’s what I think could have gone better:

• Promote, promote, promote! If these pictures were to be part of a larger campaign, creative marketing strategies to get the word out could have been used.
• Incentives. As much as we want to believe everyone cares about public health, you sometimes have to lead people with a carrot. There could possibly be red tape with giving away prizes to the best picture, but perhaps an award or certificate could have been used.
• Engage. No other users engaged with the 17 pictures, no one championed the program from the department.

So we’ve seen the good (The Red Pump Project), the bad (Stanley Cup winning Chicago…I’ve got to throw my hometown a bone!), and the different (#austinPublicHealth). The biggest take-away from this would be inviting engagement.

• Tell people what you want them to do, kindly. Share this post! Double-tap if you think #vaccines rock! 
• Take interesting pictures. We see your event posters all over town and we’re just as blind to them online as we are in real life. Snap a shot of a child wearing a bike helmet and elbow pads instead of a flyer with Bike Safety Tips listed. 
• Be a real person. People want to engage with other people, not ambiguous brands or images.
• Test NEW things. Don’t be afraid to try things out and don’t feel bad if they fall flat! 

And since we are discussing trying new things, have you tried Instagram Video? How do you like it compared to Vine? I think the length is going to be great for public health professionals, much better than a 6 second loop. What sorts of videos would you like to see for #publichealth?

(P.S. Comment below and share this with your friends!)

How and Why Should We "Pin" Public Health?

I regularly participate in the social media for public health (#sm4ph) twitterchat.  The chat (sponsored by the Public Health Management Corporation and hosted by Jim Garrow) explores various forms of social media use and how they impact (or could impact!) public health.  Back in March, the following question was posed to twitterchat participants:

At the time, I took note that several participants (including me) thought that Pinterest could be "the next big thing" (FYI: Pinterest is an online pinboard that allows users to create and share image collections):

Then this week, Nicole Ghanie-Opondo posed an important question to the field:  "Is Public Health Pinnable?"  She does a great job of breaking down all the "stuff" public health people want to pin (i.e., campaign posters, event information, staff photos) and analyzing why or why not it is a good fit for this particular communication channel.  She also emphasizes the key principle we need to remember and revisit in health communication:  

Think About Your Audience!  

When exploring any new communication channel, we need to review available data regarding the demographics and online behaviors of those users (whether it be Pinterest or Facebook or Twitter) and then tailor our content/strategies to those users.  The Pew Research Center's Internet & American Life Project is a great resource for social media user data.

In preparation for this post, I followed up with Nicole to see if she had received any feedback from public health colleagues on her post.  She shared the major theme from her (informal) feedback so far:  

Public health is not creating content to optimize pins.

I thought that was really interesting and it changes the conversation for me.  The question is not: "Should we use Pinterest- yes or no?"  There seems to be enough evidence that Pinterest is a promising communication strategy.  For instance we have: (1) strong interest in Pinterest from the field (as seen above), (2) available data on its users, (3) key audiences represented among users (e.g., women), and (4) colleagues that are successfully integrating this channel into their social media plans (e.g., CDC and Hamilton County Public Health).

Therefore, the question should become:  "How can we use Pinterest strategically in public health?"  This approach would require a discussion of the following questions:

• What audience/s should we be engaging on Pinterest?
• What kinds of content/images are most likely to be re-pinned or shared?
• How can we optimize our content for pinning?
• How are we evaluating our Pinterest efforts? (*Note that CDC's National Prevention Information Network (NPIN) recently had a wonderful webcast on social media evaluation. While Pinterest was not one of the featured channels, many of the concepts and resources would still be applicable.  The slides are available here).

Tell Me What You Think:

• Why (or why not) should we "pin" public health?
• How should we "pin" public health?
• What other planning questions should be considered?
• Please share examples of Pinterest being used successfully (or unsuccessfully) in public health!

Let's Give Paris Jackson Some Privacy and Revisit Safe Reporting on Suicide (and Attempts)!

I always cringe when the announcement of a celebrity suicide or suicide attempt comes through my news feed.  First and foremost, because it is incredibly sad to learn that anyone is suffering enough to consider suicide.  Second, because the news coverage that will follow is often invasive and downright dangerous to the rest of us.  The way the media covers suicide can influence behavior negatively by contributing to contagion or positively by encouraging help-seeking.  I have often written on this topic for Pop Health and even as an op-ed for the Philadelphia Inquirer.  However, the message is so important that it bears repeating.

According to multiple news outlets, Paris Jackson (daughter of the late Michael Jackson) was hospitalized this morning after a suicide attempt.  The story was apparently confirmed by her biological mother Debbie Rowe- Paris was hospitalized with cuts on her wrists.  Now I was already concerned that a 15 year old girl was having these personal, medical details released to the media.  Then I saw the coverage on TMZ and just got plain angry.  I won't link to it here because (1) the irresponsible coverage could be dangerous to readers and (2) I refuse to drive traffic to their site.

As a journalist (or public health communication professional) working on this story, your first stop should be Recommendations for Reporting on Suicide.  Although the guide focuses on suicide, the recommendations are highly relevant for attempt stories as well. The recommendations were developed by leading experts in suicide prevention and in collaboration with several international suicide prevention and public health organizations, schools of journalism, media organizations and key journalists as well as Internet safety experts. The recommendations are based on more than 50 international studies on suicide contagion.  Based on their recommendations, here are some of my concerns with the Paris Jackson articles:

• Sensational headlines:  E.g., "Paris Jackson Attempts Suicide, Rushed to Hospital" (US Weekly)
• Oversimplification:  E.g., "A source close to the family tells Entertainment Tonight exclusively that the reason Paris attempted suicide is because she wasn't allowed to go to a Marilyn Manson concert".
• Including photos of the method of death (or in this case attempt):  TMZ has published multiple pictures of Paris (some undated) that zoom in on her wrists to identify possible cutting scars.  This is bad for several reasons:
• 1- Without any confirmation, the writers are suggesting that Paris has a history of suicide attempts.
• 2- The writers are suggesting that anyone who cuts their body is attempting suicide when in fact, some self harm behavior is non-suicidal.  A good resource for definitions of various forms of self-directed violence comes from the Centers for Disease Control and Prevention (CDC).  There can be self harm behavior (like cutting) without the presence (whether implicit or explicit) of suicidal intent.  

A lot can be learned in public health by monitoring this media coverage, highlighting mistakes, and reinforcing safe messaging.  The Paris Jackson articles should:

• Inform without sensationalizing
• Provide valuable education to readers (including suicide warning signs, ways to help a friend/family member, and resources like the National Suicide Prevention Lifeline)
• Seek advice from suicide prevention experts before reporting on data or making assumptions about Paris' intentions or medical history
• Be hopeful! Emphasize that mental illness is treatable and many local and national resources exist

Resources:

1.  Associated Press (New!) Stylebook Entry on Mental Illness
2.  Recommendations for Reporting on Suicide

3.  The National Suicide Prevention Lifeline 1-800-273-TALK (8255)

What Do You Think?

• What was your reaction to the media coverage of Paris Jackson's suicide attempt?
• What other resources would you add to my list to support safe media reporting on suicide and attempts?

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?