Trends & Ideas

May 1994

A Public Health Approach to Prevention

At St. Mary's Hospital in East St. Louis, IL — like many other hospitals in poor urban communities — the trauma statistics are frightening. In 1993 more than 60 percent of St. Mary's 1,149 trauma cases were related to assault, gunshot wounds, or stabbings. Of the trauma victims, 74 percent were male, 89 percent black, and 57 percent 15 to 34 years old.

"The work to prevent violence is literally the work of building healthy communities," according to Deborah Prothrow-Stith, MD, assistant dean for government and community programs at the Harvard School of Public Health.

Prothrow-Stith was in East St. Louis in March to help kick off the Violence Intervention and Prevention (VIP) Project. St. Mary's convened the meeting in partnership with the school district's Drug-free School Program to gather leaders from government and social agencies, law enforcement, clergy, business, and healthcare to see what they could do to prevent violence in East St. Louis and surrounding Illinois and Missouri communities.

"What we hope to do is develop a program that can be implemented anywhere in the country that will target intervention and crime prevention," said Richard Mark, St. Mary's chief executive officer. The meeting's conveners plan to set up an umbrella organization to develop a comprehensive, team approach to deal with violence.

"It takes a village to raise a child," Prothrow-Stith told the audience, quoting an African proverb. "The children of this community are going to get your time, your attention, your money, or your resources one way or the other. And it is up to us to decide where and how."

The U.S. homicide rate, she noted, is four times that of the next highest industrialized nation, 35 times higher than the norm, and 70 times higher than the country at the bottom of the list. She pointed out, too, that violence is a function of poverty and a societal attitude, not race. For young white men in the United States, Prothrow-Stith said, the homicide rate is twice that of the next highest country, 15 to 20 times that of the average, and 35 times that of the country at the bottom of the list. And a study of violence in Atlanta and New Orleans showed that whites living in overcrowded conditions had the same domestic violence rates as blacks living in the same conditions. For both blacks and whites in the United States, 90 percent of homicide victims are killed by someone of their own race.

The problem, she emphasized, is not primarily one of gangs and drug trafficking but of our inability to get along with each other, particularly those we know, those we love, and those who look like us. "More police and stiffer sentences, or trying juveniles as adults, or three strikes you're out' won't have an impact on two people who know each other, who are drinking alcohol, who get into an argument, and who have a gun."

Prothrow-Stith, who has dealt first-hand with the effects of violence in neighborhood clinics and inner-city hospitals, wrote one of the first violence-prevention curriculums for adolescents. From a public health perspective, she said, we need to look at primary prevention, secondary prevention, and tertiary prevention. For primary prevention, she said, "we've got to celebrate nonviolence. We've got to practice getting along, and we've got to teach our kids how to get along."

Prothrow-Stith noted that our country encourages, promotes, and is entertained by violence. "It's not just movies and television," she said. "We've had a make-my-day' president; we've had a kick-butt' president; we've had presidents, whether Republicans or Democrats, whose popularity goes up when they bomb another country."

Secondary prevention, on the other hand, is needed for kids at risk of violence, Prothrow-Stith said. "We know these children," she said. They tend to be urban, poor young men (but increasingly young women as well), and those who have witnessed or been victims of violence.

Tertiary prevention is a misnomer, Prothrow-Stith noted. "We cannot prevent lung cancer by doing better surgery, and we cannot prevent violence by doing better put 'em in jail.'" Preventing violence requires a change in attitude and turning our attention earlier to those at risk for violence.

The political side, she added, is that "we are willing to spend $35,000 a year for 73 years [to incarcerate] the same young man we wouldn't give a $2,000 summer job." Almost all our money goes to responding aggressively to violence, she said, and very little to helping kids avoid getting in trouble or changing our attitudes.

Dispelling the Myths

Few patients, their families, or physicians know that cancer pain, even when the disease is advanced, can be controlled at least 90 percent of the time. And few know that when patients try to ignore their pain, "they may actually be compromising their chances for recovery as well as wrecking their quality of life," writes Jane E. Brody in the New York Times.

Cancer pain can hinder a treatment's effectiveness because it creates stress that impairs patients' immune response, limits their ability to tolerate treatment, interferes with their ability to eat and sleep, and undermines their will to live. Still, almost half of patients involved in a study of major cancer centers noted that they hesitated to report feeling pain, relates Brody. In addition to the fear of becoming addicted to narcotics, cancer patients fear being ignored or labelled a pest. "Others are reluctant to take pain medication for fear that when their pain became truly intolerable, it would then be ineffective," explains Brody.

Many physicians may share their patients' misconceptions and end up prescribing inadequate treatment. Brody suggests physicians heed the following pain management principles: "The method used should be adequate to control the pain and the treatment should be offered continuously to keep pain constantly under control."

The first step to successful pain management is to completely and precisely evaluate patients' pain, according to pain specialist Michael H. Levy, MD, of Fox Chase Cancer Center, Philadelphia. He suggests using a pain evaluation scale to help patients describe the pain's "nature and intensity" before and after treatment. Children can use a scale of faces with different expressions (from a smiling face to a tearful face) to describe their pain.

Patients, families, and healthcare professionals can obtain pain assessment tools and educational materials from Cancer Pain Relief Initiatives. The organizations, which have groups in more than 40 states, promote cancer pain management, reports Brody.

Asleep on the Job

If you have ever felt sleepy, even dozed off, at work, you are not alone. In a Better Sleep Council (BSC) survey conducted by Bruskin/Goldring Research, one-third of adults said that sleeplessness has affected how they do their job; 26 percent of men and 13 percent of women admitted they have dozed off at work.

On-the-job boredom is not the reason workers are sleepy. They are simply tired, reports BSC, citing a National Commission of Sleep Disorders Research study, which found that 40 million Americans have trouble sleeping.

Americans' sleeplessness is costly to employers. Fatigue results in poor decision making, sleep-related accidents, and lost productivity, costing between $15 billion to $50 billion each year. "Fatigue is one of the most frequently cited probable causes of on-the-job accidents," reports BSC.

Americans are not only sleeping less, they have less opportunity to sleep, having reduced their average nightly sleep time by more than 20 percent during the past century, according to the National Commission on Sleep Disorders Research. This is not difficult to explain based on information from the Economic Policy Institute, which reports that Americans have added an extra month to their annual work and commute time since 1969. When asked if working long hours has ever kept them from getting the sleep they need, 41 percent of those responding to the BSC survey answered affirmatively.

Responsibilities at home are also keeping Americans from getting needed sleep. Women who work are especially at risk for sleep deprivation because they continue to do the bulk of cooking, cleaning, bill paying, and shopping. Perhaps this is why more women than men said they do not feel well-rested when they wake for work.

"With fewer hours left for sleep, the quality of sleep we get is even more important," asserts BSC. Employers may want to pass on to their employees suggestions for a good night's sleep: stick to a regular sleep schedule (even on weekends), exercise regularly, set the room's temperature to 65 degrees Fahrenheit, and allow fresh air into the room. Breaks may help refresh workers who feel sluggish during the day.


Copyright © 1994 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Reform Update-May 1994

Copyright © 1994 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.