Monday, February 11, 2013

There's Good News, and There's Bad News

One of the most important functions of public health is to monitor the health of the communities we serve and share what we learn—we call this activity community health assessment.  We argue that when people have objective information about health, they will make better public policy decisions.  All other things being equal, I do think that is true. Of course all other things are not usually equal: in our politicized, market-driven world information is manipulated, and people don’t easily let go of strongly held beliefs even when presented with objective information that challenges those beliefs.  So we also have to spend time working to establish the conditions under which people can appreciate objective information.
I recently prepared an orientation for three new members of the Mid-Michigan District Health Department’s Board of Health.  I thought a fun way to introduce the concept of community health assessment would be to challenge the Board members to guess which way health trends are moving:  homicide deaths—up or down? Drug deaths—up or down? And let them have a freewheeling discussion about what the trends mean. I thought the exercise was a lot of fun and the trends we looked at were surprising to me, so I thought I’d share some of them on the blog.
I wanted to get easy-to-understand data which I could graph myself. So I went to the Michgan Department of Community Health’s website, and clicked on “statistics”.  I found a ton of good stuff.  For those who are interested I put some technical notes at the end of this post.
The first thing I want to share is the homicide rate in Michigan shown in the chart below. I was surprised at the clear long-term downward trend, surprised no doubt, because the recent mass shootings are on my mind.  
The chart gives the rate of homicides per 100,000 people. In 2010, 6.4 out of every 100,000 residents were intentionally killed, which is just a little over half the rate in 1988 when 11.8 residents were killed for every 100,000 (Click here for more information). 
One chart by itself can’t answer all our questions.  For example, you might suspect that homicides are down because the population is aging—a smaller proportion of the population is at the age where people are likely to commit homicide.  The MDCH website has data that address this question, showing that Michiganders of all ages are truly less homicidal than we used to be.  You might also wonder if attempted killing is rampant, but our phenomenal emergency rooms are simply saving more of the victims. That’s not it—while it’s true emergency medicine has improved, assaults are down, too. 
If we are mostly interested in gun violence, we might want to know whether the proportion of homicides accounted for by guns has changed over time.  Indeed it has and the increase in homicides you can see in the chart that goes from about 1983 to 1992 was caused by an increase in handgun violence. But on average, over time, guns have steadily accounted for a little over two-thirds of all homicides. People who worry about guns also care about suicides and accidents. Guns are used in most suicides.  In fact the rate of suicides has been fairly flat over time.  In 2010 there were 12.5 suicides per 100,000 residents, exceeding the rate of homicides.  In addition, if you believe that some places have higher homicide rates than others you’d be absolutely right. Low-income urban neighborhoods often (but not always) have high homicide rates, but so do some low-income rural areas. African-Americans are more than four times as likely as Whites to be a victim of homicide. This graph obscures the tragic disparity in homicide deaths between communities. 
And finally, even though homicides are down so much, it doesn’t mean guns are not a problem. When you combine all the forms of mortality from guns: homicides, suicides and accidents, deaths from guns are about double deaths from all forms of homicide combined. Still, given what’s on the news right now, I was really surprised to learn that, over all, we are a lot safer from homicide than we were in the recent past.
Here is another trend that surprised me: drug-related deaths. Again the data are displayed as the rate of drug related deaths per 100,000 residents. The chart below shows that between 1999 and 2010 drug-related deaths in Michigan increased over 240 percent from 7.1 to 17.3 per 100,000.
What accounts for the explosion in drug-related deaths? Chrystal meth? “Bath salts”? In fact, deaths from legal, prescription drugs outnumber deaths from illicit drugs.  Deaths from legal, prescription opioids and hypnotics increased by a factor of four during the time period covered by the chart (Click here for more information).
The data in the chart include many related ways of dying from drug use: taking drugs to get high and overdosing, mixing drugs or drugs and other substances, accidents and injuries (such as car crashes) related to drug use, and it includes prescription errors by the health care system.  One of the most commonly abused substances—sometimes called a drug—is alcohol, and this chart does not include alcohol related deaths (unless another drug was involved). Alcohol related mortality in Michigan has been fairly constant over time. In 2010, 8.1 persons per 100,000 died from a cause related to alcohol use. Deaths from legal, prescription drugs have surged past alcohol alone as a cause of death.
Many things are being done in the counties we serve to try to combat drug related deaths. Clinton, Gratiot and Montcalm counties all have programs to permit people to safely dispose of prescription drugs. The area hospitals are implementing policies to curtail drug-seeking in EDs. And many pharmacies will take back unused medications. Still, I was really surprised that drug-related deaths are 2.7 times more common than homicide deaths. 
Rattled by the scary news about guns? Well, think twice before asking your doctor for a prescription to calm yourself down!
The data in both charts are the rate per 100,000 Michigan residents. Graphing it that way protects against the mistake of thinking, for example, that homicides are trending down when really all that is happening is people are leaving the State resulting in fewer homicides.  
The reason that the most recent year in both charts is 2010 instead of a more recent year is that it takes a long time to accurately finalize the details of death certificates, especially those involving crimes, and then it takes more time to analyze the data and put it on line, especially with staffing levels at MDCH being so low.
The data have been age adjusted. Homicides are more common among younger people so in an aging population the trend could appear to be going down, even if younger people were actually experiencing more homicides per capita. Age adjusting is a simple procedure that fixes this.

Friday, February 8, 2013

You Never Know What Will Catch On: Do 1 Thing

A few years ago Mid-Michigan first responders and public health workers gathered in Lansing to wrestle with the problem of how to encourage people to take preparedness more seriously.  The idea they came up with was a marketing campaign they dubbed “Do 1 Thing”.  Do 1 thing encourages people to take a moment once each month to do one thing to be more prepared for emergencies.  It breaks preparedness down into simple steps that any family or person can take: designating a place to meet if you have to leave your home, making a plan for how you would assist an elderly relative, storing some clean water, etc.  Do 1 thing is promoted through public service announcements, a website, printed calendars, etc. At their website you can sign in and over the course of a year it will walk you through 12 simple steps to be more prepared. And you can follow it on Twitter at @Do1ThingUS.

Now Do 1 Thing is starting to get national attention. CDC is recommending its use to other communities around the country. Victoria Harp of CDC’s Office of Public Health Preparedness and Response said, “Our Learning Office has highlighted the work of the Do 1 Thing project as a great example of a Whole Community approach to emergency management.  This year our Communications Office is committing to the program.”  CDC and FEMA will be promoting Do 1 Thing to communities throughout the year.

People from the Mid-Michigan District Health Department’s service area who worked on the project included Lynda Farquharson our Emergency Preparedness Coordinator, Jennifer Churchill who was our Public Information Officer and Larry St. George and Steve Lehman from Clinton County Emergency Services. Thanks to them and everyone who worked on the project and congratulations for starting a national trend!