Sounding the Alarm on America’s Alcohol Problem

At this point in time, no matter where you live in this country, you are probably aware that we are in the throes of a major opioid epidemic. You may know that drug overdoses are now the leading cause of death among Americans under 50. You may know that in 2016, more than 42,000 people died from an opioid overdose. You may also know, that earlier this month, the United States Surgeon General, Jerome M. Adams, issued a national advisory urging Americans to carry and learn how to use naloxone, a life-saving drug which can reverse the effects of an opioid overdose.

What you may not know, is that we are also in the midst of another deadly crisis: excessive alcohol use. In 2015, more than 33,000 Americans died from alcohol-induced causes, including alcohol poisoning and liver disease. And if this tally included deaths from drunk driving, other accidents, and homicides committed under the influence of alcohol that number swells to 88,000. In fact, today excessive alcohol use is the fourth leading preventable cause of death in the United States. Over the past decade, the alcohol death rate has continually gone up at an average of 4 percent a year with a 40 percent total increase during the 10-year period.

So why is the alcohol crisis, which is responsible for twice as many American deaths as opioid overdoses, less visible? Why hasn’t anyone sounded the alarm?

The truth is drinking is ingrained in our culture. Because alcohol in moderation is not harmful, it has been normalized in our society. For many, turning 21 and gaining the right to drink is on par with getting one’s license or becoming eligible to vote. It’s a rite of passage that anchors many of life’s greatest celebrations. We raise a glass to celebrate a job promotion, we toast to the New Year, we buy beers at baseball games, and knock a few back with each birthday. In addition, alcoholic beverages are promoted through all major media, available anywhere from the grocery store to our favorite restaurants, to the sports arena. In New York City, the City that never sleeps, you can order a drink between 8 am and 4 am—20 hours out of the day.  However, alcohol can be addictive and dangerous if abused.

In 2014, the New York City Health Department found that nearly one third of New Yorkers engaged in high-risk or binge drinking, which is defined as consuming five or more drinks for men or four or more drinks for women, within two hours.

Turns out, the rest of America likes to drink as well.

According to a study published by JAMA Psychiatry, in 2017, the percentage of American adults who consume alcohol increased from 65 to 73 percent from 2002 to 2013. Though the majority of Americans who drink do so without causing significant risks or health problems, this study makes a compelling case that the United States is currently facing a crisis with alcohol abuse that is getting worse. It documents substantial increases in the prevalence of drinking  in general, increases in high-risk (or binge) drinking, and increases in the prevalence of alcohol use disorders (AUDs), with the biggest changes related to AUDs, the most serious condition.

Alcohol Use Disorder, the medical term used by medical professionals to describe someone with an alcohol problem, is diagnosed as either mild, moderate, or severe based on the number of eleven different symptoms an individual has experienced in the past twelve months. According to the study, which reviewed data from two nationally representative surveys of US adults, prevalence of AUDs increased nearly 50 percent during the time period 2001-2002 to 2012 to 2013. The researchers concluded that “substantial increases in alcohol use, high-risk drinking, and alcohol use disorder constitute a public health crisis”. They go on to say that with the increase in alcohol use and abuse, we can expect increases in related and co-occurring chronic disease, especially among woman, older adults, racial/ethnic minorities, and the socioeconomically disadvantaged.

It’s time for a national wake-up call.

It is the role of public health to sound the alarm and to elevate a national conversation around alcohol abuse. We need a national strategy to address the alarming increase in high-risk drinking and AUDs.

It is essential for public health to advocate for policies and programs that support the creation of healthy environments that encourage healthy practices over unhealthy ones. We need to adopt and implement effective messages and programs that help people understand and avoid the dangers. We also need to adopt evidence-based policies that create and support environments where the healthy choice is the easiest. Though certain to elicit resistance  and cause controversy, this may mean closing bars earlier or opening them later in the day,  changing serving sizes, limiting the number of liquor licenses, or increasing the alcohol tax.

This month, when the surgeon general announced the new advisory related to opioid use, he became part of a chorus of public health professionals advocating for different policies and societal behaviors with the potential to upend a deadly crisis.

We should be doing the same thing with alcohol abuse.

Turning the Tide on Maternal Deaths Among Black Women—One Case at a Time

In Public Health the focus is population-wide efforts to prevent sickness and premature death. We are often so focused on population-level statistics we forget that behind every single number there is a human being. We forget that it is a collection of individual stories that make up the whole. Sometimes in public health, to find a way forward, we have to look beyond the numbers and hear the individual stories to uncover the truth.

In Public Health the focus is population-wide efforts to prevent sickness and premature death. We are often so focused on population-level statistics we forget that behind every single number there is a human being. We forget that it is a collection of individual stories that make up the whole. Sometimes in public health, to find a way forward, we have to look beyond the numbers and hear the individual stories to uncover the truth.

One of the biggest public health triumphs in recent years has been the worldwide drop in maternal mortality—about a 44 percent reduction, over the last 25 years, according to the World Health Organization. Nonetheless, every day approximately 830 women die from preventable causes related to pregnancy and childbirth. Of those deaths, 99 percent occur in developing countries where mothers in rural and poor communities face a much higher risk of complications.

In the United States, roughly four million women give birth every year. In a country that has some of the finest medical care that money can buy, none of us should go into the experience fearing for our lives. We may worry about a lot of things, like the pain of labor and delivery, the health of the child and uncertainty about being a good mom, but we should be able to approach the experience fairly certain that we will come out alive. But while overall maternal deaths in the industrialized world have mirrored the worldwide trend, the United States has actually seen an alarming increase in maternal mortality and morbidity. In fact, we have the highest rates of any wealthy country. The Center for Disease Control and Prevention reports that in the United States around 700 women die each year as a result of pregnancy or delivery complications and another 60,000 women have a “near miss” or almost die. Research suggests that at least half of them are preventable.

Experts agree that there are probably three major factors contributing to the upward trend: inconsistent obstetric practice, particularly in managing emergencies; the increasing number of women who are presenting with chronic health conditions; and a lack of good data and related analysis on maternal health outcomes.

It appears race is also a factor.

Last fall when Serena Williams shared the story of her near-death experience following the birth of her daughter, she shone a startling spotlight on a growing concern in the United States—an unacceptably high rate of pregnancy-related deaths and disabilities among Black women. In the wake of her disclosure, several other articles were published and radio segments aired, many detailing examples of complications Black women from all walks of life faced while giving birth, many of them fatal.

Unfortunately, in New York City, the trend holds. In NYC, each year approximately 30 women die of causes related to pregnancy with the largest number of deaths attributed to women of color. In our city, Black women are 12 times more likely than White women to die from pregnancy-related causes.

In 2016, funding from Merck for Mothers helped the Health Department and the Fund for Public Health in NYC develop a system for tracking the number of women affected by severe maternal morbidity (SMM) or life-threatening complications. Severe maternal morbidity includes heavy bleeding, blood clots, organ failure, stroke and heart attack that result in the woman almost dying.

The results of the new system, the first of its kind in the nation to track SMM at the municipal level, showed some alarming trends. We learned that each year approximately 2,500 women in NYC experience a life-threatening complication during labor and delivery. For every woman who dies, there are 100 who almost die.

We also uncovered blatant racial disparities. Black women were three times more likely to experience a life-threatening event than White women even after taking educational attainment into account, which is frequently the equalizer. In fact, Black women with college degrees or higher were still more likely to experience a life-threatening event than women of other races and ethnicities that didn’t graduate from high school.  The story of Shalon Irving, an epidemiologist at the CDC, who died shortly after delivery, is a tragic and heart-wrenching example of this inequity.

We need to act to right this injustice but first we need to understand it.

This year, FPHNYC and the Health Department announced a new grant from Merck for Mothers to build on the work accomplished during the first grant period. The new grant will work with three hospitals to support detailed reviews of each SMM case to analyze and apply lessons learned to hospital quality improvement processes. In addition, the grant will support efforts to integrate SMM cases into the city-wide Maternal Mortality Review Committee to better understand the root causes of poor maternal health outcomes, the glaring disparities across race, and to help inform individual and community strategies to affect change.

This award opens up new possibilities. It offers the opportunity for public health officials to look beyond the big picture numbers and learn from individual mothers’ experiences to find the answers.

Taking Care of New York City: A Blueprint to Improve the Health of all New Yorkers

Overall, New York City residents are living longer, healthier lives. Though the city’s health is improving, marked disparities in key health indicators persist. Thirteen years ago the NYC Health Department established a comprehensive blueprint to improve the health of all New Yorkers and has tracked progress over time.

Overall, New York City residents are living longer, healthier lives. Though the city’s health is improving, marked disparities in key health indicators persist. Thirteen years ago the NYC Health Department established a comprehensive blueprint to improve the health of all New Yorkers and has tracked progress over time.

In 2004, the NYC Health Department launched its first comprehensive policy agenda called Take Care New York to set priorities and focus on the leading preventable causes of illness and death. The initiative identified ten priority areas for action to improve health and called on all New Yorkers to adopt them. In September 2009, Take Care New York 2012 was launched to build on the success of the initial four years and broaden its scope to include a new focus on children’s health with an emphasis on eliminating health disparities and addressing neighborhood conditions that adversely affect health. In both cases, specific and measurable objectives were established and indicators tracked to show progress over time.

TCNY 2020 was launched at the start of the de Blasio administration and represents a further evolution of the original Take Care New York policy agenda. Whereas the earlier versions focused more on what individuals and providers could do, TCNY 2020 recognizes that health outcomes are influenced by many factors outside of an individual’s control like neighborhood safety, access to healthy food, and housing quality. To achieve the twin goal of improving everyone’s health and making greater strides in reducing health disparities, it becomes imperative to engage with community stakeholders to build strong, structured cross-sector partnerships.

In response, under TCNY 2020, the Health Department has employed a more intentional approach to community engagement including holding a series of 28 community meetings for residents across the five boroughs. The resident meetings provided the opportunity for health department staff to learn from community members regarding neighborhood needs, assets, and resources and to hear directly from residents about how they experience health inequities. During a six-month period, over 1,000 New Yorkers participated in the sessions and provided input identifying reducing obesity; improving air quality; meeting mental health needs; increasing physical activity and reducing cigarette smoking as their top priorities.

Under TCNY 2020, there has also been an expanded approach to working with community-based organizations, in total over 9,000 nonprofit organizations, local businesses, schools, health care providers, faith-based institutions and community leaders have engaged on a variety of programs, policies and initiatives. For example, to address the high rate of childhood asthma hospitalizations in the South Bronx, the Health Department has partnered with the Department of Transportation and two local trucking companies to upgrade their trucks to reduce harmful emissions. Results to date show a significant reduction in nitric oxide emissions and air particulate matter, which will reduce the risk of respiratory problems and asthma attacks.

A second example is in Staten Island where the Health Department is working with the Department of Education and a local nonprofit to address the issue of childhood obesity by building school gardens, bringing nutrition education into classrooms and making sure kids are connected to primary care.

This past December, the DOHMH released its second annual update on TCNY 2020. The report updates progress across 25 key indicators that impact people’s health. Overall, New York City is getting healthier: more New Yorkers self-reported as feeling healthier than in previous years (78 percent citywide); the teen pregnancy rate is at an all time low (40.6 per 1,000) falling almost 50% between 2011 and 2015; high school graduation rates have increased from 66 percent in 2013 to 73 percent in 2016; and air quality city-wide has already surpassed the 2020 goal. A full list of the 25 indicators and most recent data can be found in Appendix 1 of the TCNY 2020 report.

In this era of chronic disease, local public health departments are frequently playing the role of “chief health strategists” in order to lead community health promotion efforts. In partnership with health care providers and leaders across a range of sectors including social services, education, transportation, public safety, and community development, public health departments are more likely to convene and work as part of coalitions than to work alone. This requires a new orientation and skill set where public health leaders are adept at building and nurturing strategic partnerships to bring about collective impact.

At the heart of this new approach is the notion that communities will drive and sustain change. Just as the health care system has adopted a patient or client-centered approach to health care service delivery; the evolving nature of public health work calls for a community-centered approach requiring authentic community engagement to both identify priority issues and to develop strategies and actions to address them. Progress will not happen overnight and as we have seen over the last 13 years of TCNY, careful goal-setting, tracking of indicators over time and applying a community approach is the blueprint for a healthier city.

Big Tobacco: A History of Death, Destruction and Deception

In the summer of 1974, I landed my first real job working in the tobacco fields of Bristol, Connecticut for $1.25 an hour. For the first part of the summer we worked in fields under white tents tying the plants so they would grow straight. The second half of the summer the women were in the sheds sewing the tobacco leaves together and hanging them, so they would dry for processing. The days were long, hot and grueling and the work was monotonous. Nonetheless, I was thrilled to be earning a paycheck and my parents were happy to have me out of the house and gainfully employed.

In the summer of 1974, I landed my first real job working in the tobacco fields of Bristol, Connecticut for $1.25 an hour. For the first part of the summer we worked in fields under white tents tying the plants so they would grow straight. The second half of the summer the women were in the sheds sewing the tobacco leaves together and hanging them, so they would dry for processing. The days were long, hot and grueling and the work was monotonous. Nonetheless, I was thrilled to be earning a paycheck and my parents were happy to have me out of the house and gainfully employed.

This was how I spent the summer of my sophomore year in high school, toiling along side hundreds of other field workers, mostly migrant workers from Puerto Rico. There were a handful of other students from my high school, but we were a minority. My first employer cultivated broad leaf tobacco to be used in the manufacture of cigars.  I didn’t stop to consider the product my employer was peddling and the disastrous and addictive effect tobacco products have on the human body. Like my co-workers, I was earning a paycheck though for me as a privileged white kid from the suburbs it was pocket money not subsistence for my entire family. I learned a lot that summer.

The CDC reports that cigarette smoking is responsible for more than 480,000 deaths per year in the United States, including 41,000 deaths resulting from secondhand smoke. This is about one in every five deaths annually and 1,300 deaths every day.

I worked in the tobacco fields 10 years after the Surgeon General released the landmark report: Smoking and Health: Report of the Advisory Committee of the Surgeon General of the Public Health Service published in 1964. Though medical researchers had started connecting the dots between smoking and lung cancer by the mid 1950s, this was the first federal government report linking smoking and specific diseases. At that time, two-thirds of men and one third of women in the United States smoked cigarettes. In response to the surgeon general’s report and the growing scientific evidence that smoking harms virtually every organ in the body, major tobacco companies joined forces to mount a defensive strategy to counter the bad publicity by denying the science and misleading the public about the dangers of smoking. The human toll has been tremendous.

Over the next 50 years the battle between Public Health and Big Tobacco raged, and it is a long and complex story. The line graph on page 18 of the Surgeon General’s 50 Years of Change report shows that the per capita number of cigarettes smoked steadily increased from 1900 to the early 1960s. The only two declines are attributed to the period of the Great Depression and then again in the early 1950s when evidence first emerged that smoking is harmful, causing cancer and all sorts of other ailments. Per capita consumption peaked at 4,400 cigarettes per year in the early 1960s then fluctuated following the first Surgeon General’s report in 1964 until the early 1970s at which point there was a steady decline through to 2012.

Against the backdrop of Big Tobacco’s relentless marketing and continued misleading the public about the dangers of smoking, the declines over the next thirty plus years are credited to federal legislation and taxes, continually emerging scientific evidence of the health consequences of smoking, broadcasting and advertisement regulations, availability of over the counter cessation medications and the fallout of the Master Settlement Agreement, a 1998 settlement between the four largest US tobacco companies and 46 states to settle Medicaid lawsuits against the companies to cover tobacco-related health care costs. In exchange the tobacco companies agreed to pay, in perpetuity, payments to states to compensate for medical costs associated with treating people with smoking related illness as well as curtail certain marketing practices.

Over time, sustained and multifaceted public health approaches to smoking cessation have resulted in a steady decline in smoking. According to the Center for Disease Control and Prevention between 2005 and 2015, the percentage of cigarette smokers declined from 21 percent to 15 percent. Yet Tobacco is still the leading cause of premature death across the country and the Tobacco Industry continues to spend billions peddling their product despite a November 2017 ruling that finally forces them to print and broadcast “corrective statements centered on the health risks and addictive nature of smoking. The November ruling stems from a long drawn out court battle that started in 1999 with a lawsuit brought by the Justice Department that was settled in 2006 with an order to place the corrective statements followed by a decade of appeals and wrangling by the tobacco companies to stall and modify the statements.

The end result is certainly a victory for public health, but the impact of the corrective statements will be less effective both because our context has changed (how we access the news) with the explosion of social media outlets and because Big Tobacco successfully argued to modify the originally proposed statements that they said were “forced public confessions” designed to “shame and humiliate them.”

What would have been wrong with that?

Meanwhile, millions more lives were lost during that decade of appeals not to mention millions of dollars in tax payer’s money was spent arguing the case. It makes you wonder, who were the real winners here?

Think Local and Give Thanks

November is the month of Thanksgiving, a time of year when Americans pause and give thanks. In this current political environment, and considering the events of the last few months—hurricanes, mass shootings, and the recent terrorist attack in New York City—I am having a hard time finding something good. Typically, I am a glass-half-full kind of person, though as we move closer to this Thanksgiving season, I have found it hard to shake this malaise.

November is the month of Thanksgiving, a time of year when Americans pause and give thanks. In this current political environment, and considering the events of the last few months—hurricanes, mass shootings, and the recent terrorist attack in New York City—I am having a hard time finding something good. Typically, I am a glass-half-full kind of person, though as we move closer to this Thanksgiving season, I have found it hard to shake this malaise.

Luckily, after my routine run this morning and some time for uncluttered thought, I have reconsidered. Sometimes you have to back off from the big picture and focus on individual wins and progress to remind yourself that there are a lot of good things happening.

For starters, in New York City, we just re-elected Mayor De Blasio for a second term. From the public health perspective, this is a very good thing. Mayor De Blasio is a public health mayor whose signature initiatives focus on what we call the social determinants of health: affordable housing, education, especially early childhood education, and jobs—all foundational to good health. Under Mayor De Blasio, we launched the Building Healthy Communities (BHC) initiative and Thrive NYC, both priority efforts to address critical public health issues that will thankfully continue during the next four years.

Building Healthy Communities is a multi-faceted, public-private partnership designed to improve health outcomes in 12 chronically underserved neighborhoods across the five boroughs by increasing opportunities for physical activity, expanding access to healthy and affordable food, and improving public safety. Launched in 2015, the initiative has leveraged millions of dollars in public capital investments to improve parks, renovate recreation centers, add street improvements for bikes and pedestrians, and transform public plazas. In addition, through community engagement efforts, we invested private funds to pilot and scale interventions to expand free exercise classes, support schools to become more green and active, and to transform underutilized space to create urban farms at public housing developments.

Championed by the First Lady of NYC, Chirlane McCray, Thrive NYC is a city-wide strategy that takes a broad public health approach to the challenge of mental illness. Launched in 2015, the initiative aims to change the way people think about mental illness and how City government and partners deliver mental health services. Thrive NYC is based on six key principles with a total of 54 different initiatives designed to drive change and align action to improve the mental health of the population. Over the last two years, Thrive NYC achieved many milestones including establishing mental health clinics in community schools, providing training in Mental Health First Aid, launching a city-wide campaign to raise awareness and reduce stigma, and launching a mental health help line.

In both cases, the initiatives are examples of the power of public-private partnership and the importance of multi-sector stakeholder engagement to advance public health. Neither is a quick fix and both will require ongoing effort and support to achieve systems level change. We must stay the course.

Earlier in the month, I was in Atlanta Georgia attending the annual conference of the American Public Health Association. The conference is the single largest gathering of public health professionals with over 12,000 attendees from the US and around the world including public health leaders, advocates, academics, researchers, activists, practitioners and students. It was good to hear about the work happening in other places.

The issue of health equity was front and center at the conference with clear evidence that health equity is becoming a driving theme and a priority focus of local health departments as well as other community based groups across the country. There is clearly a renewed commitment to confront racism and other forms of discrimination and exclusion. I heard about many successful examples of programs designed to address the social, economic, and environmental conditions which create unjust differences in health and engage communities in new ways. Efforts like the BUILD Health Challenge, an initiative to improve community health by aligning funding, capacity building, and multi-sector partnerships to target upstream factors that impact health, increase health equity and lower healthcare costs. BUILD was launched in 2014 by a consortium of funders and has supported work in close to 40 communities nationwide.

The conference was an injection of hope and confidence that across this nation there is transformational public health work happening. Despite the dysfunction in Washington, DC and ongoing efforts that threaten current public health and healthcare legislation, there is momentum at the local level. Individual citizens, organizations, towns, and business are making progress. I left feeling a renewed sense of optimism and thankful that across our great nation there is an army of smart, dedicated public health professionals working to make our world a healthier place.

Now that is something to be thankful for.

Is There a Cure for Violence?

We live in a violent culture. Not a day goes by that we don’t read about another act of senseless violence. From the proliferation of mass shootings like what we saw in Las Vegas a few weeks ago to the youth stabbing here in a Bronx High school last month. Predictably, there have been renewed calls for action, be it gun control or improving school safety standards. Though both are important, they are singular solutions. We need to apply a public health approach to bring a comprehensive solution to our complex and multi-faceted epidemic of violence.

Applying a Public Health Approach to our Nation’s Violence Epidemic

We live in a violent culture. Not a day goes by that we don’t read about another act of senseless violence. From the proliferation of mass shootings like what we saw in Las Vegas a few weeks ago to the youth stabbing here in a Bronx High school last month. Predictably, there have been renewed calls for action, be it gun control or improving school safety standards. Though both are important, they are singular solutions. We need to apply a public health approach to bring a comprehensive solution to our complex and multi-faceted epidemic of violence.

Violence is a leading public health threat in our nation today impacting the health and safety of our communities. It is a leading cause of injury, disability, and premature death that disproportionally impacts youth and people of color. The United States is far more violent than other advanced nations. According to a 2016 study published in The American Journal of Medicine, Americans are 10 times more likely to die from firearms than citizens of other developed nations. And a chart developed by Kieran Healy, a professor of sociology at Duke University shows that the United States is about three times as violent as 23 other wealthy nations.

We started talking about violence as a public health issue over 35 years ago. In 1979, the United States Surgeon General’s Report, Healthy People, identified stress and violence as one of the top priority areas for the nation. The report stated that violence can be prevented and clearly recognized violence as a public health issue that can be addressed using a public health approach. In 1980 a landmark report by the Department of Health and Human Services, Promoting Health/Preventing Disease: Objectives for the Nation, established the first ever national goals for violence prevention.

Still, in 2015, 17,793 people were victims of homicide and 44,193 took their own lives. Homicide is the third leading cause of death for young people ages 10 to 24 years old. In 2014, 4,300 young people were victims of homicide—an average of 12 per day. For the same year, another 501,581 were treated in emergency departments for injuries sustained from physical assaults.

So what do we mean by a public health approach to violence? We mean prevention. The public health approach includes collecting data and doing analysis to define the problem, identifying the people and communities at greatest risk while identifying both risk and protective factors and then developing and testing prevention strategies. Once strategies are proven effective, they must be adopted at scale.

Violence is preventable, not inevitable. The public health approach is built on the premise that violence is a learned behavior that can be unlearned or not learned at all. It is based on evidence that violence is rooted in complex, underlying issues and is often a predictable behavior in unsafe environments in which people live and raise their families.

Cure Violence, a neighborhood-based, public health oriented approach to violence reduction and prevention, is one that has shown promising results. The program employs community-based “outreach workers” as well as “violence interrupters” in neighborhoods with high rates of gun violence. These workers use their relationships, networks and influence in a community to dissuade specific individuals and residents perceived to be at risk for committing a violent act not to engage in violence. The evidence indicates that when Cure Violence strategies are implemented as intended there is the potential to “denormalize” violence in whole communities.

Cure Violence was launched in New York City in 2010. Today there are 18 programs around the City. A recent evaluation conducted by the John Jay College of Criminal Justice, City University of New York documented gun violence trends before and after the opening of two programs in the South Bronx and East New York, Brooklyn. In the South Bronx, gun injuries were down 37 percent after implementation and in Brooklyn, gun injuries were down 50 percent after implementation. Additionally and probably most important, young men in neighborhoods with the Cure Violence program reported declining support for violence as a means of settling disputes. The study provides promising evidence that a public health approach to violence reduction and prevention works.

Violence affects people in all stages of life and there are different forms of violence—child abuse, youth violence, intimate partner violence, sexual violence, elder abuse and suicide. All are strongly interconnected. There are many examples of successful initiatives that are being implemented around the country.  We have learned that by using a public health approach, we have an opportunity to create and sustain evidence-based solutions to prevent violence.

So what are we waiting for?

Just in Case: Emergency Preparedness and the Role of the Health Department as First Responder

When it comes to disasters there is one indisputable fact: they happen whether we are ready or not. New York City is no stranger to natural or man-made disasters. In the last two decades we experienced Hurricane Sandy, which was the second largest storm to make landfall in US history, and the September 11 terrorist attack on the World Trade Center.

When it comes to disasters there is one indisputable fact: they happen whether we are ready or not. New York City is no stranger to natural or man-made disasters. In the last two decades we experienced Hurricane Sandy, which was the second largest storm to make landfall in US history, and the September 11 terrorist attack on the World Trade Center.

Despite the inevitability of hurricanes and other catastrophes, most individual citizens probably don’t spend a lot of time thinking about the next disaster much less preparing for it. I have lived in New York City for over thirty years and for the past 23 I have been married to a New York City firefighter. My husband’s three brothers are NYC police officers so you might say I have had a fairly up close and personal view of the life of a first responder. If any family should have an emergency plan we should. To be completely honest, we don’t.

So it is good to know that behind the scenes at the federal, state, and local levels there is a network and system for emergency response and preparedness at work around the clock. They work in tandem to anticipate and prepare for a multitude of different scenarios, natural and man-made, that are unlikely to cross our conscience except in our darkest nightmares.

The Federal Emergency Management Agency (FEMA) takes the lead nationally. FEMA’s mission is to support both citizens and first responders to build, sustain, and improve our capacity to prepare for, protect against, respond to, recover from, and mitigate all hazards. It is a huge job and one that continues to grow in importance as we manage more and more weather events, disease outbreaks, and terrorist threats. It’s why the proposed 900 million cut to FEMA that Congress was considering for the 2018 federal budget must be reconsidered!

To do its work, FEMA collaborates with both elected officials and state and local agencies like NYC Emergency Management (NYCEM). In planning for and responding to city-wide emergency events, NYCEM is responsible for organizing and coordinating with all other New York City agencies, some like Police and Fire that one might expect to be on the front lines of a wide-scale emergency but others that you may not consider like Department of Buildings, Department of Citywide Administrative Services, Department of Parks and Recreation and the Department of Health and Mental Hygiene.

The NYC Health Department, which most of us associate with birth certificates, smoking restrictions, restaurant grades, and other local health-related issues, will take on the role of first responder in the event of a major emergency such as a coastal storm, a biological attack, or a disease outbreak. Like Police and Fire, the Health Department is constantly preparing and training behind the scenes for any number of emergency scenarios. And in New York City, with its 8.4 million residents, this is a tall and expensive undertaking. It’s also a critical one that must be built and sustained with adequate Federal funding.

When Hurricane Sandy caused the East River to flood the generators that kept the Neonatal Intensive Care Unit of NYU Langone Medical Center running, an established protocol and trained staff made sure that all patients were safely transferred to other hospitals.

In the instance of a biological attack like anthrax, taking certain medications after exposure before the disease develops can keep people from getting sick. To prepare, the Health Department has identified 165 Points of Dispensing (PODs), temporary sites that can be activated within hours to provide life-saving medications city-wide. Rapid, city-wide mobilization requires practice and continued support for complex exercises to continually test and improve plans.

When the first Ebola patient was admitted into a city hospital, the Health Department’s Public Health Laboratory was able to confirm the diagnosis in less than three hours. The Health Department lab is an essential part of controlling potential outbreaks as highly trained and practiced technicians are constantly at the ready to test and detect a variety of infectious diseases and minimize the spread.

In 2004 when FEMA marked September as National Preparedness Month (NPM), it did so to coincide with the onset of hurricane season and to elevate the importance of emergency preparedness. This September, as we bear witness to the damage of hurricanes Harvey and Irma and mark the 16th anniversary of the 9/11 attacks, it is essential that we realize that our country’s and city’s readiness is the result of foresight, planning, and coordinated training which requires sustained attention and funding over time.

Often times, and thankfully, many major emergencies never come to fruition, but we must prepare nonetheless. It is critical that our federal government maintain the investments necessary so that we can continue to plan and respond in ways that save lives and protects the health and wellbeing of all of us.

An Idea Whose Time Has Come: The Opioid Epidemic is a National Emergency

On July 31st, the Trump Commission on Combating Drug Addiction and the Opioid Crisis issued their interim report. Their first recommendation was to urge the President to declare a national emergency under either the Public Health Service Act or the Stafford Act. The report goes on to recommend five additional immediate steps to combat the epidemic with the promise of a fuller report and additional strategies to be released this fall.

Sara Gardner, MPH
Executive Director

On July 31st, the Trump Commission on Combating Drug Addiction and the Opioid Crisis issued their interim report. Their first recommendation was to urge the President to declare a national emergency under either the Public Health Service Act or the Stafford Act. The report goes on to recommend five additional immediate steps to combat the epidemic with the promise of a fuller report and additional strategies to be released this fall.

My initial reaction was to think, it’s about time!

My second was to wonder, what took them so long?

And my third thought was, how did we get to this place?

The report paints a compelling picture of an epidemic that started to unfold over a decade ago and grew throughout the early 2000s because of overprescribing of prescription drugs, which were heavily marketed by pharmaceutical companies as non-addictive treatment for chronic pain. By the time doctors, patients, and the government began to realize the issues with prescription meds, opioid misuse was rampant and people were turning to drugs such as heroin because it was cheaper and easier to obtain.

Though I work in Manhattan I live in the borough of Staten Island. Staten Island, like thousands of other communities across the nation has been fighting this opioid epidemic for almost 10 years. No one has to tell us that this epidemic has reached emergency proportions. For years now the local paper has shone a spotlight on the epidemic from all angles including weekly reports of overdoses as well as the community, City, and State response. The recommendations in the Trump Commission’s report that relate to increasing treatment capacity; prescriber education; expansion of medication assisted treatment; and widespread dispensing of the overdose reversing drug naloxone are already underway in Staten Island and throughout  New York City.

Today, drug overdoses have become the leading cause of death among Americans under the age of 50, with two-thirds of those deaths attributable to opioids. In 2016, 62,000 Americans died from overdoses, 19 percent more than 2015. While NYC’s overdose rate is lower than other regions, in 2016, NYC lost an estimated 1,300 people (3-4 per day) to drug overdose. An estimated 80 percent of those overdose deaths—approx. 1,075—involved an opioid.

Since 2011, heroin and subsequently, fentanyl—a powerful synthetic opioid 50 to 100 times stronger than the painkiller morphine—have driven the increase in overdose deaths. Almost 90 percent of the fatal opioid overdoses in NYC involved heroin and fentanyl. Eighteen percent involved prescription opioid painkillers. Before 2015, fentanyl was involved in fewer than five percent of all overdose deaths in NYC. In 2016, fentanyl was involved in approximately half of NYC overdose deaths.

This year, the de Blasio administration launched a comprehensive, multifaceted initiative called HealingNYC: Preventing Overdoses, Saving Lives, to address the rising epidemic of deaths from opioid drug overdoses. The initiative, which will ramp up evidence-based efforts already underway, will spend $38 million annually with the goal of reducing opioid overdose deaths by 35 percent over five years. The initiative has four overarching goals: preventing overdose deaths; preventing opioid misuse and addiction; protecting New Yorkers through effective drug treatment; and protecting New Yorkers by reducing the supply of dangerous opioids.

HealingNYC will build on a record of leadership and innovation by expanding what we know works and implementing 12 separate strategies that in addition to preventing opioid misuse, expanding treatment and reversing overdoses, will also expand efforts to reduce the availability of illegal opioids, particularly those involving fentanyl to support our ultimate goal of saving lives and reducing overdoses.

So, how did we get to this place? For more than one hundred years, death rates have been dropping in the United States but because of opioid overdoses and the rise in other deaths of despair such as suicides and alcohol-related deaths, the trend is reversing. More federal dollars are definitely needed to expand what we know works to scale in order to successfully stem the current epidemic.

The bigger question is how do we prevent future ones? How do we prevent the next generation of addicts? More and more addiction experts are pointing to the many social, environmental, and psychological issues that contribute to drug use.  Addiction is a symptom of despair and a sign that something is really going wrong in our country. We need to get to the root cause and address the underlying issues. We owe that to the thousands who have died and the families that loved them.

Policy Shift and Budget Cuts Prevent Progress in Unwanted Teen Pregnancies

As the nation focuses on the debate raging around the repeal of the Affordable Care Act and the current health bill being debated in the Senate, little attention is being paid to the fate of the very successful, national Teen Pregnancy Prevention program. Administered through the Office of Adolescent Health, the program has contributed to an unprecedented decline in teen pregnancy rates—from 34 births per 1,000 girls in 2010 to 22 per 1,000 in 2015. That’s a 35 percent decrease over five years. Despite this progress, President Trump’s FY17 budget proposes a 50 percent cut to the program. It’s pretty hard to fathom such a decision, especially when the United States still has one of the highest unwanted teenage pregnancy rates among developed countries, including Canada and the United Kingdom.

As the nation focuses on the debate raging around the repeal of the Affordable Care Act and the current health bill being debated in the Senate, little attention is being paid to the fate of the very successful, national Teen Pregnancy Prevention program. Administered through the Office of Adolescent Health, the program has contributed to an unprecedented decline in teen pregnancy rates—from 34 births per 1,000 girls in 2010 to 22 per 1,000 in 2015. That’s a 35 percent decrease over five years. Despite this progress, President Trump’s FY17 budget proposes a 50 percent cut to the program. It’s pretty hard to fathom such a decision, especially when the United States still has one of the highest unwanted teenage pregnancy rates among developed countries, including Canada and the United Kingdom.

Established in 2010 by the Obama administration, the Teen Pregnancy Prevention (TPP) program is a national, evidence-based program that funds organizations across the United States working to prevent unplanned teen pregnancy among youth ages 10 to 19. The program provides $100 million annually to diverse organizations willing to replicate prevention approaches which have been rigorously evaluated by an independent group and then reviewed by the US Department of Health and Human Services. Grantees are required to use one of 44 different models based on their specific needs. It’s comprehensive, adaptable, and it works.

The irony behind the proposed cut is that teen pregnancy prevention is actually one of the few issues that Democrats and Republicans seem to agree on. According to the National Campaign to Prevent Teen and Unplanned Pregnancy, the issue has wide bipartisan support. A January 2017 survey shows that 85 percent of adults, (89% of Democrats and 75% of Republicans) favor maintaining federal funding for the Teen Pregnancy Prevention Program. In addition, the survey showed that 79 percent of adults (81% of Democrats and 73% of Republicans) believe teens should receive more information about both abstinence and birth control as well as sexually transmitted infection protection.

But widespread scientific and public support of comprehensive sexual and reproductive health education may not be enough to prevent the proposed cuts. It is likely that much of the funding from TPP will flow to abstinence-only programs which, despite research showing their ineffectiveness as a stand alone approach, have received over $2 billion dollars in funding over the last 25 years. Adolescents who take virginity pledges, a hallmark of many abstinence-only programs, are less likely to use contraception once they commence sexual activity, and they are just as likely to get sexually transmitted infections. They are also less likely to seek STI testing and treatment. Put plainly, these programs aren’t effective.

Instead, New York City uses a massive multi-pronged public health effort which includes government, community-based organizations, foundations, schools, parents, and youth themselves. This approach has supported the steady decline in teen pregnancy rates—down 53 percent since 2000. Though the credit for this decline is shared by numerous organizations and various private and public funding streams, the role of TPP, the very program President Trump has decided to cut, has been significant.

At the Fund for Public Health in New York City we have collaborated with the NYC Department of Health to implement programs such as Bronx Teens Connection and the current TPP-funded initiative called NYC Teens Connection which expands important work piloted in the Bronx to Brooklyn and Staten Island. Bronx Teens Connection was designed to address the high rates of teen pregnancy in the borough by improving student access to sexual and reproductive health education and services. The program, which began in 2010, supported partnerships among 40 schools, clinics, and youth services organizations working together to connect young, at-risk students to school-based health centers and community clinics.

After five years, more than 6,000 South Bronx teens had received sexual and reproductive health education in over 20 high schools, and the number of 12- to 19-year-olds receiving contraception increased by over 40 percent. The latter stat is particularly important because experts argue that contraception has been a major factor in the decrease in unplanned teen pregnancies.

The TPP-funded NYC Teens Connection builds on this work and has enabled students, teachers, and health practitioners throughout the city to combat high teen pregnancy rates by ensuring adolescents have access to accurate and up-to-date information about their sexual and reproductive health.

While parenting has its challenges at any age, we know that it can be particularly tough for adolescent parents. We have more than enough data to prove it. Teen girls who have babies are less likely to finish high school and they are more likely to need public assistance. They are also more likely to have children who have poorer educational, behavioral, and health outcomes over the course of their lives. It goes beyond the teen and child; the societal impact is huge.

Of all the public health issues we face as a nation, this is one challenge where the numbers are going in the right direction. Unfortunately, the Trump administration’s efforts to decrease this funding undermines the significant progress we have made over time.

It’s a wonder this is still up for debate.

Mental Health Is A Public Health Issue

The World Health Organization defines mental health as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.”

The World Health Organization defines mental health as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.”

By definition, good mental health is integral to our ability to survive and thrive, as individuals and as a city. However, health professionals haven’t always held this view. In fact, the move towards a more sensitive, holistic understanding of mental illness is relatively recent.

Historically, mental illness was viewed by many cultures as a form of punishment for sins, a flaw in the family bloodline, or as an aggressive and untreatable illness. As a result, the history of how we have handled mental illness is pretty horrific and includes asylums, exorcisms, lobotomies, and isolation. Over time, these extremes gave way to more progressive ideas about treating mental illness. Archaic treatment procedures lessened and scientific study, medicines, campaigns, and public education efforts ushered in more sensitive treatment approaches.

We have come a long way, but we still view and treat mental illness separately from physical illness and health despite clear evidence they are related. There is still tremendous stigma associated with mental illness, and as a result, there is great reluctance to address the issue openly. In New York City we know that one in five adults experience a mental health disorder in any given year. Among our youth, 8 percent of New York City public high school students report attempting suicide, and 73,000 report feeling sad or hopeless each month. In addition, consequences of substance misuse are among the leading causes of premature death in every neighborhood in New York City.

And New York City is not alone. According to the World Health Organization, mental illness results in more disability in developed countries than any other group of illnesses, including cancer and heart disease. The Center for Disease Control estimates that 25 percent of all U.S. adults have a mental illness and that nearly 50 percent will develop at least one mental illness during their lifetime. Despite these statistics, in the U.S. it has only been since 2010 that mental health and substance abuse treatment have been included as an “essential benefit” that all private insurers and Medicaid have to cover. Unfortunately, the current American Health Care Act that just passed the House and is now in the Senate would make this requirement optional. This would be disastrous and a major setback to the progress we have made.

Thrive NYC Roadmap to Mental Health for All is a plan for completely overhauling the mental health system in NYC. The report or Roadmap is a multi-year program for doing this and includes 54 targeted initiatives guided by six principles: Change the Culture, Act Early, Close Treatment Gaps, Partner with Communities, Use Data Better, and Strengthen Government’s Ability to Lead. A year later, there is much progress to report including: the successful launch of a destigmatizing ad campaign; diversion programs that help people with mental illness receive treatment instead of being sent to jail and; mental health counselors in schools. The early success of this work is undoubtedly tied to its comprehensiveness.

As we approach the end of Mental Health Month, let’s reflect on these achievements. We are shifting the culture of mental health. It is no longer acceptable for mental health work to operate in a silo hidden away from other important health initiatives. Mental health is public health. It must be included as part of our goals for individual and collective health.