psyc-123: The Psychology, Biology and Politics of Food
Lecture 19 - The Law and Opportunities to Improve Nutrition and Health (Guest Lecture by Stephen Teret) [November 10, 2008]
Chapter 1. Introduction to Dr. Stephen Teret [00:00:00]
Professor Kelly Brownell: Good morning everybody, hope you all had a wonderful weekend. I'm delighted today to be able to bring to you a guest speaker, Professor Stephen Teret from Johns Hopkins University. Stephen's been kind enough to come and speak to this class before. In return, I go down and speak to a large class that Stephen teaches at Johns Hopkins. It's always very interesting for me to do that, and I hope interesting for Stephen to come and speak to you.
He's a pioneer in the application of the law to public health. As you can see from the slide there, he has training in the law, then went back to school at Johns Hopkins School of Public Health to get his Masters Degree in Public Health. He has a very interesting background in legal experience, having worked as a civil rights attorney in New York City for some time, practicing law in the state of New York and then coming to the world of public health law through his connection with Johns Hopkins.
For many years he's been on the faculty at Johns Hopkins school of Public Health. There he is a Professor in the Department of Health Policy and Management. He's also the director, as you can see, of The Center for Law in the Public's Health at Johns Hopkins University, a collaborative venture between Hopkins and Georgetown University, and has made a real mark in the world of public health through the application of the law.
I first got to know Stephen at a meeting with The Robert Wood Johnson Foundation put together on issues of diet, nutrition, and obesity. They brought in people who had used the law in other areas, and Stephen Teret had made a real mark in the area of gun control and violence prevention, and had a lot to say based on his experience there on the diet, nutrition, and obesity area, and has really had a phenomenal impact there, and national impact has been involved New York City's policies on gun control and violence and the like; and has more recently become interested in the area of diet, nutrition, and obesity and has really been powerful — a powerful ally in that fight as well.
He's a remarkable person, creative, ingenious, interesting in the way he applies the law to issues of public health, particularly the issues that we're talking about in this class. I think you'll enjoy hearing from him. Let's please welcome Professor Stephen Teret.
Chapter 2. Freak Accidents or Foreseeable Events? [00:02:26]
Professor Stephen Teret: Thank you very much Kelly. If I'm so creative and genius, how come I do lecture nineteen? I guess one of the easiest ways is to state the relationship between gun violence and obesity would be to say eat well or I'll kill you, but that's not what I wanted to talk about to you today.
What I was hoping to talk to you about is in general, public health and public health strategy, public health policy, and how strategies and policies that have been shown to work in other areas of public health might — and that's a question that you should explore — might work in trying to reduce the incidents of obesity worldwide or in the United States in particular. I think that I'll probably focus more on trying to address childhood obesity than obesity in general today.
Kelly mentioned that I spent a portion of my career in working on the area of gun violence prevention. I'd like to use that as one of the examples, or perhaps the principle example, about which I'll be talking with you today, trying to draw parallels.
Let me start by telling you about an incident that happened some time ago here in New England, where it was a Friday afternoon and a young boy whose name is Ross — he was about thirteen — was let out of school earlier than normal. School — not just Ross but everybody was let out, including Ross's friend Stephen. Ross and Stephen went to Ross' house where they were just hanging out, playing, goofing off and the phone rang. Ross answered it and it was his mother.
His mother said to Ross, how are you doing? Fine, he said, I got out early. She said, so what are you up to? He said, I'm just hanging out here with Stephen, we're playing. Ross's mother said, you know Ross, I've told you this before, but I don't like you being alone with Stephen. There's just something about this kid Stephen — Ross's friend, that Ross's mother didn't like. Ross said to his mother, you're right, I'm sorry, we'll leave. So they left Ross's house and they went to Stephen's house.
I want to point out that Johns Hopkins actually has desks that we provide students. If any of you are thinking of graduate school, you might want to think of Hopkins. They went to Stephen's house and Stephen says to Ross, come with me I want to show you something. So they went upstairs to the bedroom that Stephen's parents shared and Stephen goes to his father's closet, opens the door and reaches up to the shelf in which Stephen's father has his sweaters or other things, and Stephen takes down a Beretta semi-automatic pistol.
Now I don't know if you're familiar with a pistol; what a pistol is as opposed to a revolver? Do any of you not know the difference between a pistol and a revolver? Okay, a revolver if you watch old cowboy movies, a revolver is the thing that has six bullets in it and when the trigger is pulled the cylinder revolves — hence the name — so it lines up the next bullet with the barrel of the gun. A pistol is squarer in shape. A pistol — if you watch movies on HBO, you'd see pistols instead of revolvers — a pistol is square in shape and the bullets of a pistol are contained in something called the magazine, sometimes called the clip and it fits into the butt of the gun, the back end of the gun.
Stephen takes down this Berretta. Beretta is an old company. It's a company that's more than five hundred years old, started in Italy, but they have a Maryland branch, Beretta U.S.A., which actually is in my state Maryland, in Accokeek, Maryland. Beretta is a popular gun, a popular pistol. Stephen pushes a button on the side of the Beretta, and that button discharges the magazine — remember that the magazine is what contains the bullet — and Stephen puts the magazine, the bullets back up so he now has the handgun, the pistol without the magazine in it, and he says to Ross, let's go out and play.
They're outside, they're in the driveway of Stephen's family's home and horsing around. At some point Stephen says to Ross, he holds the gun like this — this is how people hold guns in movies now — and Ross is bent down a little bit and Stephen goes bang and pulls the trigger, but a bullet exits the gun. The bullet entered Ross's face just to the left of Ross's nose and traveled in a slightly downward path.
So Ross is now in the driveway, laying down in the driveway exsanguinating, and Stephen is going crazy. He runs into the house because he's going to call 911, but actually the first thing that he does is he runs upstairs, goes to the closet, and puts the gun back in the closet, and he calls 911. You can listen to the tape, he's sort of nuts in fear and says to the 911 operator that his friend was just shot. That they were playing in the driveway and a shot came from the woods behind the house — he's scared, so he makes up a story.
The police come, the helicopters overhead because there's a sniper somewhere in the woods and the ambulance comes, the fire department comes, and the police are talking to Stephen. They realize that this is a made up story, and Stephen quickly tells them the truth what had happened, but he said that he didn't know that there was a bullet in the gun because he took the bullets out of the gun.
The ambulance takes Ross to the local hospital. Ross's parents are contacted, and they get there in time to sign the consent that allows the surgeons to harvest Ross's organs because Ross is brain dead, and they might as well do what they can for someone else, since there's nothing that they can do for their son anymore.
How do things like that happen? When you read about things like that in the newspaper it says freak accident, but for people who work in public health — and how many people here are students in The School of Public Health, The Yale School of Public Health? When you work in public health, you come to understand that these aren't freak accidents because there is a pattern to them. These boys were thirteen years of age, the highest age group — highest risk age group for something like this happening is about thirteen years of age, males not females.
The pattern in public health is called the epidemiology of these events. There's a pattern as to what are the high risk guns, what are the high risk times of day, times of the year. Because there's this pattern, this epidemiology of these kinds of gun injuries and gun deaths, these gun injuries and gun deaths become, to some extent, foreseeable.
It's not a freak accident in that this happens over and over again when you work in the field of gun violence prevention, one of the sad things is you come into work in the morning and someone you don't know has sent you an email or sent you a photocopy of a newspaper article with the same kind of story.
Unfortunately, I'm in a position where I could tell you story after story, after story of thirteen year old boys who were playing together and one of them got killed by gunfire. You become the depository of these terribly sad stories. It's terribly sad on an individual basis, but it's terribly sad on a population basis, because I say that they're foreseeable, and if they're foreseeable then it seems that they also should be preventable.
Chapter 3. Strategizing Prevention and Policy Investment [00:13:29]
What we as public health people try to do then is to come up with ideas about how would you prevent something like this from happening? What prevention strategy — there's a world of prevention out there — so what prevention strategy might work best so that the next foreseeable event of one thirteen year old boy shooting and killing another thirteen year old boy doesn't happen?
I know it's 9:00, I know that many of you are undergraduates, and therefore non-functional at 9:00 a.m. on a Monday morning, but let me ask you just to see if you're responsive, or whether we should sign a consent form for you. Let me ask you: how would you go about preventing something like this? You don't want the next event like this to happen. What would you do? Do you think there's something that would work? Is there a strategy? Does anybody have a suggestion? I can go ahead if you don't have suggestions. Yes please.
Professor Stephen Teret: That's a good idea. If you couldn't hear — was everybody able to hear that? — okay, the comment was we rarely see someone with a tie as attractive as the one that you have on. Thank you very much, that's very kind of you! Your second comment was — why doesn't Kelly wear these ties? I don't know.
Your second comment was if people are going to have a gun and they have children in the home, then maybe there should be some permit for having the gun in the home that also has children, and the permit could be tied to some kind of educational intervention where the people learn about what's safe. Thank you, that's good. Anybody else have a suggestion. I won't make fun of you. Yes.
Professor Stephen Teret: Not allowing guns to be stored at home entirely. Good, thank you very much. One more, yes please.
Professor Stephen Teret: Require the use of gun law so that ammo be stored separately from and require — and have ammo be stored separately from the gun itself. Good. All good suggestions.
But not all suggestions are going to have equal effectiveness. I mean, that just stands to reason that not everything would be equally effective. So how do you figure out what's going to be the effective intervention? How do you figure out what's going to be the effective intervention for preventing childhood gun-related deaths or preventing childhood obesity?
We need to come up with ideas or models. Let me present to you, or let me ask you if you will, to engage in a fiction with me for a minute about guns. Think of a gun, an individual gun as having a lifespan, and think of that lifespan as having certain markers in it. So the beginning of the lifespan of the gun would be the manufacturer of the gun. That's the birth of the gun, it's created, the manufacturer and the design of the gun by which it's manufactured.
Then the next marker in this fictional lifespan of the gun would be when the gun is sold, or the purchase of the gun. Then the next marker in the lifespan — so think of there being a timeline here, and at the beginning of the timeline is the birth and manufacturer of the gun, then there's the sale of the gun — the next marker in this fictional lifespan of the gun is the possession of the gun or the carrying of the gun. Then let's have as the last marker in this fictional lifespan of the gun, the use of the gun or the pulling of the trigger.
You could have policy that addresses these different markers in the lifespan of the gun. You could have policy that addresses the use of the gun, the last one, saying thou shalt not point a gun at somebody and pull the trigger. We do have policy. We have a lot of policy in the United States. There are federal laws, there are state laws in every one of our states, there are local laws about shooting. You could also have policy in each one of the other markers of the lifespan of the gun. But, those policies may not be equally effective, as I was mentioning to you before.
What I would like to suggest to you is that if you thought about the lifespan of the gun with these markers, and you had effectiveness with high effectiveness and low effectiveness, if you plotted out the likelihood of effectiveness, my suggestion to you is that the effectiveness would be much higher at the early part of the lifespan of the gun than it would be down here at the use of the gun.
Down here, we've already manufactured millions of guns. In the United States, we manufacture about three million new handguns every year, put them into the stream of commerce. Again, down here at possession and use, we've already manufactured the gun. We've already figured out, or someone has figured out what they want to do about the design of the gun. The person is already carrying the gun or possessing the gun.
What we would say in terms of policy for the use of the gun is, you know the gun that you have in your hand, that the gun that you have in your pocket? We always want you to act kindly and prudently with that gun even though sometimes you may be filled with alcohol or other drugs, sometimes you may be filled with rage, sometimes you may be filled with rage for very good reasons, because we live in an unfair world and there are things that do engender rage in an unfair world; but when you are filled with rage and with alcohol or something else, we want you when you have this gun on you, we want you not to use the gun in a violent way against someone else. That's foolish in my mind.
If you really want success, if you want effectiveness — defining effectiveness is reducing the incidence of gun violence in the United States — then you need to shift your focus back. We can have laws about possession. Most of our laws in the United States about possession have been making it easier to possess a gun, concealed carry laws that many states have passed. We can have laws about sale; we do have laws about sale. I don't know if any of you have gone and bought a gun, some of you are too young to buy a handgun under federal law, but we have laws about sale or purchase of guns.
Until recent times, the law about sale of gun is the person who wants to go in and buy a gun — and I just got contacted by a lawyer recently who is representing a man who is a quadriplegic, because an eighteen year old person went into a pawn shop, bought a gun, the gun was illegally sold to the eighteen year old person. The eighteen year old person then went to a shopping center and with that gun and one other gun shot up the shopping center in Salt Lake City, Utah killing a number of people and severely wounding others. So there's a lawsuit against the pawn shop for violating the laws or the policy regarding the sale of a gun.
What we've relied upon with regard to policy for the sale of a gun is a person — like this eighteen year old who went into the pawn shop — a person comes into a place that sells guns, looks in the display case of a gun — of guns and says to the clerk, I'd like that one. So the clerk has a pad, and tears off the top page of Form 4473 of the Bureau of Alcohol, Tobacco & Firearms — now it's called Bureau of Alcohol, Tobacco, Firearms & Explosives — and asks the intended purchaser to please fill out Form 4473.
The person looks at Form 4473 and it says, hey are you a fugitive from justice? The person thinks and no I don't recall that and checks no. It says, are you a convicted felon? No. Have you been adjudicated mentally incompetent? How many people are going to — thank you for reminding me, I remember the adjudication now; yes, you ought not to sell me the gun.
I have a friend, Clark Deets, who is a forensic psychiatrist to the stars in Los Angeles, who before he did that was a Professor at University of Virginia and he went to the Virginia Hospital for the criminally insane or some name like that, where everyone by definition had been adjudicated mentally incompetent. He passed out a questionnaire saying to each person, have you been adjudicated mentally incompetent? 75% of the people said no; I mean they're mentally incompetent, why would they say yes?
We relied upon self-reporting as our policy for trying to keep guns out of the hands of people who we thought were disproportionately dangerous. But instead, we can look at the manufacturer of the gun, and the design of a gun, and make decisions as a public about whether we want three million new handguns made every year in the United States; and if we do want three million new handguns made every year in the United States, how do we want those guns to be designed?
There are certain things on guns called magazine disconnect devices and loaded chamber indicators, that might have prevented this kind of tragedy from happening to this boy Ross. A loaded chamber indicator is a kind of thing on the gun that tells you whether there's a bullet in a gun. What happened with Stephen's father's gun is Stephen took out the clip but there was this thing called the round in the chamber. There was still a bullet contained in the gun that wasn't in the clip or the magazine that Stephen took out. That situation so frequently results in injury or death to others, because people didn't know there was a round in the chamber.
But you can have a device on a gun that's called a loaded chamber indicator, a little piece of metal that sticks out or it could be more sophisticated like a red light that comes on, that tells you that there's a bullet in the gun. Would you buy a camera that didn't tell you whether there was film in the camera? Would you buy a car that wouldn't tell you whether you had gas in your gas tank? I don't think so, but everyday people buy guns that don't tell them that there's a round in the chamber, a bullet in the gun, even though the device that would tell you is something that was patented more than a century ago and would cost less than a dollar to put on guns, and some guns have it so it's imminently technologically feasible.
Or there's something called a magazine disconnect device, where if you take out the magazine as Stephen did, even though there's still a round in the chamber, without the magazine in the gun, you can't pull the trigger and discharge the bullet. So Ross would not have been killed had this gun had a magazine disconnect device on it. Again, the patent for magazine disconnect device is more than a century old, and the cost is less than a dollar again, and it exists on a very small percentage of guns, but it's technologically feasible.
It doesn't exist on most handguns, and it doesn't exist on most handguns because we don't regulate them as to their design. We don't look all the way back here at the point of manufacture for formulating our policy, even though that would be the most effective kind of policy.
Chapter 4. Comparing Firearms and Food [00:27:16]
So what, if anything, does this teach you about food? I'm not sure that I know the answer and I won't know the answer to a lot of the comparisons here between firearms and food, because I'm not as smart about food policy as Dr. Brownell is or many of the other people who will come lecture you in this course. But it seems to me that if we say, let's regulate eating — if you think of there being a lifespan with regard to food being the manufacturer, or the growing, or the processing of the food, the marketing of the food, the purchase of the food, the eating of the food — if we put our policy investment down here at the end of the lifespan of the food for eating. You can walk into the supermarket, you can walk into the convenience store, you can buy whatever garbage you want no matter how obesigenic the food is, but we're saying to the people once they've done that, but please be careful about eating the food, that just doesn't make sense to me. We can try to regulate the purchase of the food, but it may be that that too is of relatively low yield in effectiveness.
Marketing may buy you some more, we market food to kids — I don't know if you've already have lectures on marketing of food to kids, but that seems like something that's imminently well regulated or could be — isn't well regulated now, but could be well regulated. There are people like Jennifer Pomeranz — have you met Jennifer Pomeranz? Jennifer Pomeranz is raising her hand now, and Jennifer Pomerantz is the Director of Legal Studies and Legal Initiatives at The Rudd Center and Jennifer works on — among other issues, she works on the area of marketing of food to children as a means of reducing the risk of childhood obesity.
You can look also at the manufacturer, the processing of food about how much high fructose corn syrup is going to go into food unnecessarily, perhaps how much salt is going to be in the food which may be only indirectly related to obesity, but salt is said to kill 150,000 people in the United States unnecessarily from the kinds of hypertensive diseases and renal diseases that come from eating too much salt that doesn't have to be in food.
We need to think about how do we want to invest our regulatory efforts and our legal efforts with regard to food policy. One way of doing that might be this type of thing similarly to how I discussed about this with guns, with the public health principle here being it's better to provide the population with some kind of automatic protection where they don't have to do something.
They don't have to make a decision every time they want to put something in their mouth, every time they get into a car they don't have to make the decision about how they're going to give themselves safety. We put airbags in cars, which are automatic protection, we want people to buckle up also, but we put airbags in cars — I may talk about that a little more in a couple minutes — because we want them to be automatically protected where they don't have to do something to avail themselves of the benefit of the airbag.
We want to do something automatically for people which is best done at the time of manufacture so that they don't always have to be considering what should they be doing when they're making decisions about what to eat, and how much to eat, and what are the contents of the things that they're eating, particularly if they're in a restaurant and they don't know what the content of the things is that they're eating.
Chapter 5. Narrowing the Circles [00:31:16]
I want to talk to you about another public health model that deals again with guns, but I think is applicable to other issues. Think of the universe of people. Do you remember venn diagrams in high school? When you were in high school you learned about venn diagrams, is there anybody who didn't learn about venn diagrams? Should we explain venn diagrams to somebody?
When I was in high school I had a great math teacher. He was a great math teacher, but not withstanding his greatness, I was a uniquely poor math student. But, one of the few things that I do — lawyers don't have to be good math students — all lawyers have to know how to do is divide by three, because your contingency fee is one-third of what you get for your client, and so we're genetically — we're very good at dividing by three but we don't do other quantitative things quite as well.
This math teacher taught us about — he said think of the Triborough Bridge. You're going over the Triborough Bridge, which is in New York City if you're not from there, and there is a big sign that says Bronx two right lanes, Manhattan three left lanes, but there are only four lanes. This is a venn diagram.
Think of the beginning of a venn diagram as being the universe of people. People, some of whom may want to have guns, and maybe from a policy point of view, it's okay for some of these people to have guns; but maybe it's not okay for some people to have guns. Then think of — I once was debating somebody about guns and this man was saying that all we have to do to reduce the incidence of gun deaths — this was at an American Academy of Pediatrics meeting and this was a famous yet perverse pediatrician — and what he was saying is all we have to do to reduce the incidence of gun deaths is teach people the safety rules about guns.
He would say, and as you can see on my next slide — this is before there were PowerPoints, they were slides and they were remote control things — but he would turn it and point it at the screen, instead of at the slide projector. Which here is a man who is saying all we have to do is teach people the basics about gun safety, and he's pointing his gun in the wrong direction. Let me point my gun in the right direction here.
You also have a universe of guns. It may be that there are some guns which it's okay for people to have, and some guns for which it's not okay for people to have, so the key area becomes this area, the overlap in the venn diagram, this area which were it shaded, I could say the shaded area — being the people, certain people, who are allowed to have certain guns but then there are some people, the felons, the adjudicated mentally incompetent, the fugitives from justice, etc. — there are some people who should have no guns and there are some guns, 50 caliber guns for example, that no people should have.
The point of view with regard to gun policy is that what we want to do is we want to move those circles away from each other so that we're minimizing this non-shaded shaded area, so that there are more people who are in the proscribed category, like maybe it's not only felons, but maybe it's people who were convicted of a violent act that would have been a felony but the courts were too crowded, so it was reduced to a misdemeanor so they're misdemeanants rather than felons; but maybe they shouldn't be allowed to have a gun. Or maybe there are more guns like Saturday Night Specials — the cheap handguns that are sort of like the starter guns for someone launching his criminal career — that no one should be allowed to have. As a policy means, what we want to do is move those circles away from each other so we're narrowing that area.
What if instead we had nutrition circles? Again, you have people and here you have foods, different kinds of foods so in the people category you have adults, you have kids, you have people who have predilection for obesity. In the food categories you have good foods, you have unhealthy foods, you have foods that are obesigenic, foods that are high in sugars, foods that are high in salt.
You also have places, places being things like schools — why don't we just leave it at schools if we're dealing with children — and if you look at what the policy is about food, it's essentially that anyone can eat any food in any place. We don't have policies with regards to foods that regulate who should be eating what in what places.
Again, we could change that. We could move the places circle down so that for instance in schools there are some foods that you can eat but there are some foods that you ought not to be able to eat; move the foods circle out, move the people out so that ultimately this area over here is — doesn't have to be minimized, but we want to make sure that some people who shouldn't be eating certain foods in certain places like schools, are not doing so.
Chapter 6. A Haddon Matrix for Food [00:38:13]
Let me talk to you about one more area of conceptual models. I want to talk to you about something called The Haddon Matrix. Bill Haddon was a genius of a man and he's now deceased. He was a physician, he was trained in public health, he went to college, to a school — I can't remember what's the school that begins with an "H," he went to where Jennifer went, he went to Harvard, and he went to MIT.
He was a health officer in New York State, a county health officer in Westchester County and he became the first administrator of what's now called The National Highway Traffic Safety Administration which is the Federal Government Agency that controls the design of vehicles and a number of other things to try to reduce the 42,000 deaths that occur on the highways in the United States every year.
Bill Haddon, who is also the father of the field of injury prevention said, if we're thinking of ways to address a problem, why don't we think of there being certain factors. The factors being over here that are pre-event, event, and post-event; I'll explain those to you in a second. Let's also — I'm sorry, the factors being here, human, vehicle, physical environment, social, legal environment; and the phases being pre-event, event, and post-event.
What Haddon meant by this is for the phases, if you think of injuries occurring during motor vehicle crashes, and he created this matrix principally for motor vehicle crashes, but then realized that it was widely applicable to other public health problems. The event would be the actual crash of the car, but there are things that can be done that reduce the likelihood of an injury before the car crashes, and after the car crashes, as well as at the time the car crashes. Those things can deal with humans who are involved in this, they can deal with the vehicle — that would be the car in this case — or they can deal with the physical environment or the social cultural and legal environment.
The reason — one of the reasons that Haddon came up with this matrix is because most interventions, the knee-jerk reaction to interventions are interventions that occupy this cell: the pre-event human cell. The pre-event human cell is characterized by educational interventions.
Now, I don't want to bad mouth educational interventions too much, because sometimes they might work. Somewhere there might have been an educational intervention that worked. I recognize that I'm basically in a psychology class, so I don't want to say that educational interventions never work. I'm an educator, I don't want to say that educational interventions never work. But we would be misplacing our policy capital if we only looked to that one cell of a multi-celled matrix.
I'm sure you each have your own personal stories that you could tell. Let me tell you one of mine. Kelly said I used to be a lawyer, I was a plaintiff's trial lawyer in New York State and I decided that I wanted to go to public health school and work in the field of injury prevention. I went to Johns Hopkins School of Public Health, the largest, the oldest, the number one rated school of public health in case any of you were thinking of post-graduate or graduate work, a school of public health where — I don't know if I said this before, but where we actually have desks for students.
I went to the school of public health and I sat at the feet of the goddess of injury prevention, a woman named Susan Baker, and I was learning everything about injury prevention. I was living in a row house, this is what in other areas that are not Baltimore would be called townhomes, but in Baltimore they're still called row houses which are connected, single family houses that are all connected, so you have a wall that separates you from the adjoining row house housing a different family.
One day I was downstairs in the basement with my son Michael, who must have been six or seven years old, and my wife and my daughter were out away from the house. My then youngest child Christopher was upstairs in his crib taking his nap, and I was playing with Legos. I don't know if people know what Legos are anymore — you know what Legos are — so we're playing with Legos, these little building blocks that you put together, and I go, Michael do you smell something burning? Michael — no, so I said, I'm going to go upstairs and check, you stay here.
I run upstairs, nothing on the first floor, I run up one more floor where Christopher is taking his nap, don't smell anything, okay I made a mistake. I come back down to the basement and there's a crack in the wall that separates our row house from the other row house, and I see black smoke coming through the crack and I say, Michael there's a fire next door. Michael you go outside and don't cross the street or anything, but walk to the end of the block and just stand there on the corner, I'm going to go get Christopher, I'll meet you there in less than a minute. He does that, I go upstairs, I grab tiny baby Christopher, run out — who's now almost thirty — and run out of the house with tiny baby Christopher.
I see the house next door now is engulfed in flames that have broken the windows and the flames are lapping up on the outside of the house and now everyone in the whole community has gathered because you could smell it, you could hear it, that a row house is burning, it's frightening, so I get to the corner, there are a bunch of people there and I say to a neighbor, you take Christopher, here I've got to go back in to get the valuables.
Oh God, well how stupid, I'm an injury control student, I know this kind of stuff, you never enter a burning building or a smoky building. I give Christopher to a neighbor, I go back in — the house now is filled with black sooty smoke, it's clawing at your throat, I make my way in the darkness, it's the middle of the day but the house is filled with black smoke, I grope my way upstairs to the bedroom to get the valuables, and it was at that point that I realized that I'm a graduate student, and by definition, therefore, I have no valuables. I mean what am I going to get? There's nothing there.
But I also recognize that the street is filled now with scores of neighbors. I'm not going to come out empty handed and look stupid in front of the neighbors, so I grabbed the toothbrushes and I come out — I got the toothbrushes. I mean, what a dumb thing to do. You don't do that, I'm supposed to be an expert, or a budding expert in injury control, I have learned, I've been the subject of educational interventions that tell me that you don't enter a building; but people aren't always smart.
If you invest all of your effort in this cell of educating humans to always act prudently, you're going to miss a whole lot of other opportunities that you shouldn't miss. With regard to going back to Ross and Stephen and guns, with regard to what can you do to prevent these kinds of things from happening, you can have educational programs. You can have them if you want, but I don't know how much you're going to get out of them.
You could have humans wear bulletproof vests; you could have humans have physical resilience so if they're in a car crash, if they get shot, if they're healthy and strong, then maybe they're not going to die from that kind of injury. You could change the vehicle, in this case the vehicle being a gun by having loaded chamber indicators, which before the event — before the trigger is pulled — would tell you that there's a bullet in the gun. You could have these magazine disconnect devices that I mentioned to you so the trigger is pulled, the event occurs, but a bullet doesn't come out of the gun; I'm not going to go over all these things.
You could change the environment, the physical environment, have gun safes — this is not meant to be a safe gun — but a gun safe in the home, so that people store their guns, change the physical environment of how they store the guns. You could have emergency medical services with easy access changing the environment, so people have easy access to emergency medical services. You can — in the social and legal environment you could, have trauma systems which would be a post-event strategy. You could legally ban guns were it not for a recent decision by the United States Supreme Court which would be pre-event strategy.
I don't think I'm going to take the time to discuss what that means but there are things that can be done, if you think about what does The Haddon Matrix offer you. It's a tool for thinking about prevention. It shows you that you don't have to focus solely on that one human pre-event cell for your interventions; you should expand your mind and think about other things, and you don't have to fill in every single cell when you're trying to do a Haddon Matrix, nor do you really have to worry.
One of the ways that The Haddon Matrix gets ruined in discussions is people will have endless talmudic debate over which cell does a particular intervention or proposed intervention belong in. Who cares? The purpose of The Haddon Matrix is to allow you to think through all kinds of interventions, and it doesn't really matter if Kelly says it goes in one cell, I say it goes in another cell, what matters is that we thought of the intervention.
You could think of trying to make a Haddon Matrix with the event not being a car crash, or the event the event the pulling of a trigger, but the event being excessive caloric intake. You could think of how would you feel this in. We won't have time or opportunity in our short time today about how you would fill it in, but there are things that you could do, and again, the purpose of doing this is to give you an opportunity to expand your fields of interest.
For the — and the other thing about The Haddon Matrix you're allowed to say stupid things and then just say, all right but we would never do that. For the human factor, you could educate people in the pre-event phase, you could have bariatric surgery that makes your stomach much smaller so you can only eat a little bit during the event phase. Bulimia, you ought not to do that, that's a very, very bad idea but that would be a post-eating event way of not having so much obesity. But again, let me stress this is a very bad idea.
With regard to the vehicle or vector — those are epidemiologic terms, in this case it would be the food that you're talking about. Food is the vehicle, or the vector, vector is a living thing, sometimes we eat living things, sometimes some people eat living things. In the pre-event phase, you could have food that's low in calories, you could have smaller portions during the event phase. All of these slides will be made available to you so you don't need to copy this down. Again, I want to stress that you don't have to fill in every ,' its okay. You may have ideas for what goes in the cells; when I was trying to make these slides I didn't have such good ideas.
With regard to the physical environment, you can have something that allows for stores to exist in inner city areas that sell healthy foods, rather than foods that are unhealthy. You could have menu labeling, change in physical environment, so you walk into a fast food store and there's menu — there's a sign that tells you how much calories are in the item that you're considering ordering. Or you can change the social or the legal environment and — as a law you could eliminate the subsidy for corn, which would result in perhaps less use of high fructose corn syrup, and perhaps less calorie dense foods.
As a result, you could regulate the sale of foods: something that we don't think about a whole lot, but should children be allowed to buy any food they want? Should a young child be allowed to go into a convenience store and buy a majorly large bag of potato chips or a soft drink containing a lot of sugar?
Chapter 7. A Word of Caution against Being Myopic [00:53:25]
You could also as a post-event legal intervention, you could engage in litigation. Not only litigation suing McDonald's, etc., for making people fat but engage in litigation for other things that maybe you'll discuss in this course, like the possibility that some food manufacturers may be actually trying to make their food have an addictive quality. The point with regard to The Haddon Matrix is: don't allow yourself to take a myopic view of policy by only focusing on that human pre-event educational intervention cell, you should look at a lot of different kinds of policies.
My school of public health is called The Johns Hopkins Bloomberg School of Public Health because a man named Bloomberg, who is the mayor of New York City happened to give in the hundreds of millions of dollars to then find his name on the side of the building, for which we're very, very grateful, but Mike Bloomberg when he was a student at Johns Hopkins, was very much influenced by an article that was published. He was interested in business back, then even though he was an engineering student.
There was an article that was published in the early 60s in The Harvard Business Journal called Marketing Myopia. It was written by a man named Theodore Levitt. What Levitt said in this article, which is a classic — and Theodore Levitt unfortunately just passed away a few months ago — what Theodore Levitt wrote was that sometimes companies do poorly because they're myopic. He gave, as an example, the train industry, railroad industry. At one time the railroad industry was considered the very best investment that anyone could make. There were rulers of countries outside of the United States who would invest in the United States railroad industry, but the railroad industry has not done well, as is the case with many other industries, and Levitt's argument was because the railroad industry was myopic.
The railroad industry thought that it was in the business of trains, when Levitt suggests it was in the business of transportation. If it realized that it was in the business of transportation, the railroad industry could have become also the automotive industry, the airline industry — parenthetically neither one of those are doing too well right now — but they were when Levitt wrote this article. He was saying don't be myopic about what your business is about.
Our business in public health is about saving lives millions at a time, and we shouldn't be myopic about what our opportunities are with regard to prevention policy. They're far more than just trying to tell people to always act prudently when they're making decisions that will affect their publics — their health and the public's health.
Chapter 8. Key Questions for Selecting Policies for Public Health [00:56:46]
I want to go through now quickly ten questions that I would like to suggest to you for considering when you're selecting policies to protect the well-being of populations. The first question — and again you'll get these questions on the slides, so you don't need to write this down — the first question is to identify what's the public health goal that you're seeing to achieve? You need to keep that public health goal in mind. I think that what we're talking about, other than the guns and the other examples I've given you, is that we're talking about reducing the incidence and the severity of childhood obesity.
It's important to keep your public health goal in mind, because you can get pulled away into political goals or other types of goals that may not lead you to the same place as your public health goal. It's also to keep in mind that if we are public health people, and I know that many of you are not yet public health people, but when you come to Johns Hopkins that actually has desks for students, you will become public health people.
Public health people have public health in mind, not everyone else has public health in mind. When we come up with public health interventions, policy interventions, they may be interventions that other people don't like. We say for example, there ought to be a law that requires motorcyclists to wear helmets when they ride on their motorcycles on the highway. We do that because we don't like the idea of traumatic brain injury, but motorcyclists like feeling the wind through their hair and they may have an interest that's higher in their mind that the pleasure of feeling the wind through their hair than what we think of as the foremost interest, which is a public health interest. So we should keep that in mind to remain adequately humble about what we want to do.
The second question is, if you've addressed your public health goal, then what policy objective if any, will help you achieve that public health goal? Again, as I've said to you already, not all policy objectives are going to be equally effective. So you could have as your policy objective educating the person who feeds the child if you want to, as your public health goal. You want to reduce the incidence and severity of childhood obesity, you could regulate marketing to children, you could regulate the caloric density of the food, and you need to think again through this process of what best allows you to achieve your public health goal because there'll be differences. I'm not sure if that's a question or a stretch; it was a stretch, okay.
The third of these three questions would be, by what tool is that policy that you've chosen best created? There are different tools. There's legislation, there's regulation, there's litigation, there are tools that deal with collaborative voluntary efforts. I think you already had Dr. Derek Yach talk with you about things that maybe collaboratively people could do with industry to try to reduce how calorie-dense foods are. There're programmatic efforts, but you should think through these different tools. It's not that you have to devote yourself to only one tool. These are not mutually exclusive categories; you could be doing legislation at the time same time you're doing regulation, at the same time you're doing litigation.
I mentioned earlier that maybe I would take just a minute and say something about airbags in cars to you, so let me do that here. When I first came to the field of public health, in injury control, motor vehicle related injuries were the worst problem — there were 52,000 deaths a year in the United States rather than the present 42,000 that we have now, and we wanted to reduce the incidence of motor vehicle deaths and one way of doing that, people were convinced — correctly so — would be to get airbags in cars.
We tried to get airbags in cars by having Congress mandate it. Politically that was very difficult to do. We tried getting airbags in cars by having the regulatory agency, the one that I mentioned earlier, National Highway Traffic Safety Administration, make a regulation requiring airbags in cars. That, too, was very politically difficult to do.
We turned to a third tool, we turned to litigation. There was an article that was published in a magazine called Trial Magazine, the magazine of what was then called The Association of Trial Lawyers of America, an organization of about 60,000 plaintiff's trial lawyers. These are the lawyers bringing lawsuits.
The article said to these 60,000 plaintiff trial lawyers, when you have a client come into your office, a client who has been in a car crash, a client who has suffered paralysis as a result of that, or who has brain damage; or who has facially disfiguring scarring as a result of a frontal collision; don't think only of suing the driver of the other car. Think about suing the car manufacturer for failing to offer an airbag in cars, because for decades the car manufacturers knew and proved that airbags would be extremely effective in reducing the incidence of morbidity and mortality that results from frontal or frontal oblique car crashes.
As a result of that article, a lawyer in Birmingham, Alabama had a client whose name was Rebecca Burgess. Rebecca Burgess was eighteen years of age, she had just graduated high school, she'd been a cheerleader, she was going on for some additional education. She was driving a Ford and she was in a frontal collision. If you look at pictures of Ms. Burgess before the crash and after the crash, you couldn't recognize them as being the same person. In the crash, she was rendered a brain damaged spastic quadriplegic. The lawsuit was brought against Ford saying you should have put an airbag in the car.
Ten days into the trial, the lawsuit was settled by the payment of Ford of $1.8 million dollars to Ms. Burgess. I told you before that lawyers are good at dividing by three; $1.8 million divided by three is some large number — told you that I'm not good at math — so lawyers know that's a hefty fee, so as a result of that and the publicity, there was publicity among lawyers, there was publicity among the public, I got to go on The Today Show because I was the person who wrote the article in Trial Magazine, and talk about this kind of thing.
As a result of all of that there was a tidal wave of litigation, so much so that at the end of 1985 when Ford Motor Company had to file its forms with the Securities & Exchange Commission, as corporations do, it said to the Securities & Exchange Commission that for that year 1985 it had pending against it an airbag litigation claims the amount of $1.1 billion dollars. That, coincidentally or not, was also the year that Ford decided to offer airbags as an option in cars.
Litigation can be a potent tool in protecting the health of the public, whether you're talking about cars, whether you're talking about guns, or actually whether you're talking about food. One of the things that The Rudd Center is making a real mark on is understanding how litigation can be used as an effective tool in reducing the incidence of obesity, particularly among children.
The next question is, you need to know: what the major barriers are to achieving your policy objective? There are going to be barriers that deal with legality, there are going to be barriers that deal with costs, there are going to be barriers that deal with personal freedoms, there are going to barriers about bad science. I said to you that one of the things public health people try to do was to get legislatures at the state level to pass laws requiring motorcyclists to wear helmets. I used to go to a lot of motorcycle helmet hearings and legislative committees. They're great theatre.
My favorite thing was listening to a motorcyclist testifying once saying that you don't want motorcyclists to have to wear helmets because they interfere with peripheral vision. He said that what he, as a safe motorcyclist does, whenever he's riding down the highway, is he has one eye looking straight ahead at the roadway and the other scanning the periphery — perhaps kind of lizard life capable of doing that. But you look at the legislators who were listening to this and going, yes sure you would want to do that. So bad science is one of the issues that you sometimes have to deal with as a barrier to achieving your policy.
You need to learn how you can overcome those barriers. One way is by appealing to children. It's always easier to get policy made if you're dealing with children than if you're dealing with adults, because everybody wants to protect children. You can have exemptions to policy so that your most stringent critics are exempted from it. This happens with things like vaccine policy where you leave a little loophole in mandatory childhood immunization laws saying you don't have to have your child vaccinated if it violates your religious beliefs or your philosophical beliefs. So sometimes these exemptions are useful. You will be relying upon the police powers of the states. Those are the powers reserved by the United States Constitution to the states, to protect the well being of the public. You can try to rebut bad science with good science.
The next question is that of is there adequate science to support your policy objective? Sometimes the decision makers, legislators don't care about whether there's adequate science, like with the lizard life being able to look in all directions. Sometimes you can act in the absence of science, sometimes you can simultaneously to advocating for policy create the science, do small studies, do studies that are very scientifically relevant as The Rudd Center is committed to doing, and sometimes even the science can come afterwards, after the policy has been made.
A very difficult issue is, how do you deal with opposition from within your field? That's tough to deal with, but it always come up whether you're talking about environmental policy, whether you're talking about public health, whether you're talking about anything. Fortunately for academics, we live in a field of great freedom where we're all allowed to voice our opinions and we like to disagree with each other, so you frequently will have opposition from within your field, you can compromise when necessary, you can try to achieve consensus. If that doesn't work you have to have the courage of your own convictions in the field of trying to protect children from obesity.
We have an example of that happening right now with regard to a difficult legal issue called preemption where part of the public health community says we don't care if the federal government preempts states from making more stringent laws. Other people within the public health community say we do care about that, and you have to try to figure out a way to either resolve that or go ahead with the courage of your own convictions.
Not only will you have opposition from within the field, but you'll have oppositions that's external to your field that you can expect compromise when necessary. Just be smarter, work harder, be willing to play hard ball. There's a quotation from Goethe that I like which says, "Be bold and mighty forces will come to your aid," so rely on the fact that if you're bold about pursuing in a strong way your policy objectives, sometimes you'll be lucky and some mighty forces may come to your aid like what happened last Tuesday.
You also need to be able to assure that you'll have proper implementation of your policy. If implementation goes awry, then everything that you were trying to do will go awry. It's not enough to put the policy in place, but the implementation of the policy is of great matter.
And lastly, you need to remember that you're going to have to evaluate your policy. You should plan on that from the beginning. You should have unbiased evaluators, you should evaluate both process and outcome — you can learn about those when you come to Hopkins — and based on your evaluation you also should ultimately revise your initial strategies or your initial policies.
Here you have a number of different ways of thinking about, as public health people tend to do, of thinking about how do I formulate policies, how do I choose among competing policies, how do I get policy put in place, and implemented properly? We need to think about these things. We need to think about these things because we have so many problems. We don't only have the problem of childhood obesity, we have a problem of obesity in general at the same time that we have a problem of obesity, we have problems of undernutrition, we have problems of emerging infectious diseases, we have problems of violence.
The world is beset with problems. What the world needs ultimately are public health heroes to address these problems. These problems can be solved. It takes long time to solve these problems, but they're not going to be solved without these kinds of public health heroes and those public health heroes I hope, will be you. Thank you very much.
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