"Call the Midwife": Public Health in the 1950s and Today

Are other people in love with "Call the Midwife" like I am?  I started watching last year during a break between Downton Abbey seasons.  The show follows the lives and work of nurse/midwives working in the Poplar community of east London in the 1950s.  The community has a high poverty rate and limited resources.  The series is based on the memoirs of Jennifer Worth, who like the main character Jenny Lee, became a midwife at the age of 22.

Season 2 of Call the Midwife (airing in the U.S. March 31-May 19, 2013) has been packed with public health issues.  I have been struck by how many of the highlighted issues still challenge us today:

• Season 2, Episode 1: Jenny Lee begins to care for a young mother named Molly, pregnant with her second baby.  In the course of their visits, Jenny realizes that Molly is a victim of domestic violence.  In one especially poignant scene, Jenny soothes and encourages Molly via a conversation held through the family's mail slot. Molly has been ordered by her husband not to let Jenny in the house.

Domestic violence (or intimate partner violence- abuse by a current/former partner or spouse) is still a problem today.  The Centers for Disease Control & Prevention (CDC) estimates that it affects millions of Americans.  This violence has long-term economic and health consequences for individuals, families, and communities.  The CDC offers many resources focused on public health's role in the prevention of intimate partner violence.

• Season 2, Episode 5: Jenny Lee provides prenatal care to Nora, a mother of 8, living in poverty.  The family of 10 crowds into a 2 room flat.  When Nora finds out that she is pregnant again, she is desperate to end the pregnancy.  With the family's financial situation, she feels that it is impossible for her family to take care of another child.  Jenny confronts Nora after seeing evidence of self harm.  Jenny reminds her that there is only one way to terminate a pregnancy (abortion), but it is illegal.  Nora risks her life seeking the services of a local woman who performs abortions.

Abortion remains a hotly debated public health issue in the U.S. both at the state and federal level.  This episode of "Call the Midwife" is a grim reminder of what can happen when women do not have access to safe, legal abortions.

• Season 2, Episode 6:  After diagnosing several late-stage Tuberculosis (TB) infections in Poplar, the community physician (Dr. Turner) advocates for a screening program in the form of an x-ray van.  Dr. Turner and Sister Bernadette (a nun/midwife) make a wonderful public health argument for the resources they need.  They cite the risk factors, specifically poverty in their community, noting that families may have up to 12 people in one apartment.  The close living quarters increase the chance of spreading this infectious disease.  In fact, we meet one family in the episode that lost 6 children to TB.  As a public health professional, it was fascinating to see the promotional materials that the clinicians created to recruit people for the screening.  They papered local bars with flyers and set a large sign outside the van reading, "Stop. 2 minutes may save your life. Get a chest x-ray".

Infectious diseases and their screening, treatment, and vaccination remain key public health issues in the U.S. and around the world.  Many infectious diseases like measles or chickenpox can be prevented by vaccines.  Over the past 15 years, there has been much discussion between the public and public health communities about the safety of vaccines for children.  In January 2013, the Institute of Medicine released a report reaffirming that the current childhood vaccine schedule is safe.  In fact, they report that "vaccines are one of the safest public health options available".

Tell Me What You Think:

• What have been your favorite episodes of "Call the Midwife"?
• What other public health issues are portrayed in the 1950s that still challenge us today?

Kudos to The New York Times Magazine for Examining the "Feel-Good War" on Breast Cancer!

In last week's The New York Times Magazine, Peggy Orenstein wrote an article called "Our Feel-Good War on Breast Cancer".  The piece is lengthy but well researched, insightful, and well worth the reading time.

Peggy, a breast cancer survivor herself, hits every key public health issue- cancer screenings, treatment options, "awareness" raising, message framing, funding, and research.  As someone who has been critical of "awareness" raising, I was happy to see the issue discussed front and center.  For me, her interview with Dr. Gayle Sulik (Sociologist and Founder of the Breast Cancer Consortium) was the most striking.  A key quote from Dr. Sulik (I added the bolding):

“You have to look at the agenda for each program involved.  If the goal is eradication of breast cancer, how close are we to that? Not very close at all. If the agenda is awareness, what is it making us aware of? That breast cancer exists? That it’s important? ‘Awareness’ has become narrowed until it just means ‘visibility.’ And that’s where the movement has failed. That’s where it’s lost its momentum to move further.”

Peggy also tackles the issue that is an ongoing challenge in public health and medicine:  screening.  Screenings are tests that look for diseases before you have symptoms.  Ideally, screening will identify diseases early when they are easier to treat and have better outcomes.  For breast cancer, the key screening test is a mammogram (x-ray of the breasts).  However (as Peggy points out), we seldom hear about the research that demonstrates limited effectiveness of mammograms for reducing cancer death.  This is not the research cited in the communication materials from advocacy organizations.  We also tend not to hear about the negative side effects of screening large segments of the population.  There can be false positive tests: which subject the patient to unnecessary medical intervention and emotional distress.  There can also be over-treatment for the detected cancer, even if it turns out to be a non-aggressive tumor.

When I was working in suicide prevention, one of the best articles I read was "Screening as an Approach for Adolescent Suicide Prevention" by Dr. Juan Pena and Dr. Eric Caine.  The authors dedicate a section of the paper to key decisions and tasks to resolve before implementing a screening program.  While the public health issue and screening tests are different, I believe many of their decision points are generalizable to almost any health issue.  The table presenting these decisions and tasks is a great reminder to public health professionals and clinicians that recommending and undertaking a screening program should be strategic and the decision should be re-visited regularly.  For example, the authors highlight:

• Key Decision:  Population and Setting- Is the screening program consistent with the target population's community or cultural values?
• Key Decision:  Screening Instrument- What will be the false positives and false negatives rates in the population to be screened?  Are these rates acceptable?
• Key Decision:  Staffing and Referral Network- Are there effective treatments available for the types of conditions being screened for?
• Key Decision:  Quality Assurance- How will the screening program be monitored to ensure that protocols are followed?
• Key Decision:  Legal and Ethical Issues- Has sufficient informed consent been given to parents and youth about risks, benefits, and limits of screening?

Going back to the "Feel-Good War" article:  I like that Peggy did not just point out all the flaws in our current breast cancer screening and treatment systems.  Instead, she invited her interviewees to recommend potential improvements.  Some ideas were noted in two key areas:

• Message Re-Framing:  Rather than offering blanket assurances that “mammograms save lives,” advocacy groups might try a more realistic campaign tag line. The researcher Gilbert Welch has suggested this message, “Mammography has both benefits and harms — that’s why it’s a personal decision.”

• Funding Re-Distribution:  Peggy asked scientists and advocates how some of that "awareness" money could be spent differently. She highlights the February recommendations of a Congressional panel (made up of advocates, scientists and government officials) that called for increasing the share of resources spent studying environmental links to breast cancer. They defined the term liberally to include behaviors like alcohol consumption, exposure to chemicals, radiation and socioeconomic disparities. 

Tell Me What You Think:

• What do you think about the "pink culture" or awareness raising around breast cancer?  Will it effectively lead us to our goal of prevention?
• In addition to message re-framing and funding re-distribution, what else would you recommend to help improve the approach to breast cancer prevention, screening, and treatment?

"Call Me Crazy": Lifetime's New Movie That Champions Hope and Resilience Around Mental Illness

*Warning: it was difficult to write this post without including a few small spoilers, but I hope you'll watch the whole film anyway.

On Saturday April 20th, Lifetime debuted "Call Me Crazy: A Five Film".  The film (which boasts a star-studded cast and director list) includes five short stories that examine the impact of mental illness from various perspectives.  Each story is named after the main character: "Lucy", "Grace", "Allison", "Eddie", and "Maggie".

In the first story, we are introduced to Lucy (played by Brittany Snow).  Lucy, a law student, has recently been admitted to a psychiatric institution after experiencing a schizophrenic episode.  She is struggling to see how she can live a "normal" life that includes relationships and a career.  Her clinician encourages her to finish law school because she has insight into something very few people understand (mental illness)- so who knows how many people she could help?

In "Grace", we meet a daughter who has been living with a bipolar mother for her entire life.  Grace is played beautifully by Sarah Hyland from "Modern Family"- I loved seeing her in a dramatic role.  We see the "highs" and "lows" of her mother's condition.  We also see the devastating impact that it has on Grace's life when it is not treated.  Grace often plays the role of caretaker- making sure her mother is safe.  We see her struggle to have her own life aside from her mother's illness.

"Allison" offers the viewers a twist.  She plays Lucy's younger sister.  So we step back from Lucy's view and we see how mental illness has affected her entire family.  Allison's childhood, her sense of safety, her relationship with her parents- were all changed as a result of her sister's illness.  She has bottled up a lot of anger and finds it difficult to support her sister through her recovery.

"Eddie" introduces the only male main character.  He is suffering from severe depression.  He has withdrawn from his wife and his friends.  He has stopped receiving help from his therapist.  We watch his wife intervene after discovering that he may be thinking about suicide.

Finally, "Maggie" introduces topics that (unfortunately) are all too common these days- post traumatic stress disorder (PTSD) and military sexual trauma among our returning veterans.  Maggie (played by Jennifer Hudson) was victimized during her time in the Army and its lasting impacts are threatening her ability to have a healthy relationship with her family.  Here we get another update on Lucy- she is now a lawyer and is representing Maggie in court.

While each story stands on its own, Lucy's story is woven throughout "Allison" and "Maggie" as well.  I really liked this strategy.  Not only because I became invested in her character during the first story...but also because seeing her evolve over time helped to demonstrate some key themes from this film- hope and resilience.

As Lucy says to Maggie: "I am living proof". [Of what?] "That there is hope".  In court, Lucy reminds Maggie's judge that having mental illness does not mean that you are a bad person or a bad mother.  She also reminds him about the importance of social support, "it is nearly impossible to get well alone".  Even though we see all of these characters at their lowest point- there is still hope that they can feel better, have strong relationships, and contribute positively to the world.

It seems fitting that Brittany Snow's character delivers these messages about hope and resilience, as she is a strong advocate for them in real life.  Together with the Jed Foundation and MTV, she founded Love is Louder.  Love is Louder is an inclusive movement that amplifies messages of love and support to combat negative messages resulting from bullying, loneliness, and stigma.  She has also publicly shared her own battles with anorexia, depression, and self harm.

As a health educator, I highly recommend this film as a resource for discussing mental illness, suicide, stigma, social support, and help-seeking.  Since each story is approximately 20 minutes, they can be broken down into segments or watched all together.  This film is a great example of Entertainment Education, which is an area of public health that acknowledges the strong impact that television and movies play in educating the public about health issues.

If you or someone you know is struggling with a mental illness, please reach out:
National Suicide Prevention Lifeline (1-800-273-8255)

Emergency Response to the Boston Marathon Bombings: Looking to Social Media for Information, Resources, and Connections

Boston is my second home.  I lived there for 6 years.  I went to school there.  I made some of the best friends of my life there.  I got married there.  I spent many Marathon Mondays along the race route cheering for friends, colleagues, and absolute strangers.  As many have reported on the news, Marathon Monday is the best day of the year in Boston and you have to experience it to truly understand its excitement and feeling of community.

I am absolutely heartbroken about yesterday's bombing at the Marathon.  In tears, I sat and watched the news alone in my home.  However, I did not feel alone.  As news broke, I quickly connected with Boston friends via text and social media to make sure they were okay.  Many had been watching at various points along the route.  I also connected with public health colleagues to follow the news and to catalog resources and information being deployed to my friends in Boston and also to those of us watching from home.

As with Hurricane Sandy last November, I think it is important to document all the ways that social media is being used to disseminate information and support public health and emergency management.  Here are the key themes that I saw:

Immediate Public Safety Concerns and Instructions

With the #tweetfromthebeat hashtag, Boston Police communicated regularly with twitter followers, instructing marathon spectators to clear the area around the finish line and refrain from congregating in large crowds.

Investigation

To assist with the investigation, Boston Police and FBI are asking all spectators and eyewitnesses to submit video and photos taken at the finish line.  This message has been widely disseminated via social media.

Reconnecting Runners, Spectators, and Resources

As we have seen with emergency management of natural disasters, social media and technology play a critical role in reconnecting victims with their families and friends.  For example, the following resources were quickly deployed on social media:

• American Red Cross: Safe and Well
• Google: Person Finder
• Google document: Local Boston residents offering shelter to displaced runners/friends/families

Resources for Journalists

Along with tweets from respected news organizations and reporters reminding each other not to speculate early on in the investigation, there were also formal resources circulated regarding how to effectively cover such a story.  For example, the Dart Center for Journalism & Trauma offers comprehensive resources on the reporting of disasters and terrorist attacks.  A resource focusing specifically on the Boston Marathon bombings was tweeted out:

Mental Health & Support Resources

Many public health professionals linked to resources to support those in distress following the bombings and/or those who needed help communicating about the events (e.g., discussing it with children).

HHS Secretary Sebelius tweeted about federal disaster resources:

Philadelphia (like many other cities) tweeted about local disaster resources:

Massachusetts General Hospital and other organizations tweeted out tips for discussing the Boston Marathon bombings with children:

As I discussed in my coverage of Sandy, the power of social media also brings challenges to public health and emergency management.  We have seen some early postings about the lessons learned from this event- which does include a discussion of concerns such as rumors spreading rapidly on social media.  For example, it was first reported that cell coverage in Boston was being turned off so that additional bombs could not be detonated remotely.  We later learned that information was not true.  The cell service was slow or not operational due to the extreme overload of users trying to communicate simultaneously.  There was also a lot of concern about very disturbing images of the crime scene and victims being shared on social media.

So there is much to learn about the use of social media for public health and emergency management through close examination of this event and others.  In any case, it is very clear that social media needs to be a part of every organization's disaster and response plan. 

Tell me what you think:

• What was your impression of the use of social media by federal/state/local organizations yesterday after the Boston Marathon bombings?  
• Can you share additional examples of how it was used effectively?  
• What did you see that concerned you?

Writing Public Health Blogs: Do We Get Back What We Put In?

Last week I attended a great webinar hosted by AcademyHealth called: “Traditional and New Methods for Disseminating What Works”.  One of the speakers was Dr. David Kindig and he touched on the evaluation component of writing a public health blog- do we get back what we put in?  As the tweet below indicates, this is an important question for all of our blogs.

My exploration of this question nicely coincides with the theme for this week’s National Public Health Week- “Return on Investment”.  I was initially going to write just my own thoughts, but then decided it would be a much richer piece if I could incorporate input from other public health bloggers.  The following colleagues were kind enough to send me their thoughts:

Jim Garrow: The Face of the Matter, Public Health Memes

Elana Premack Sandler: Promoting Hope, Preventing Suicide for Psychology Today

Jonathan Purtle: The Public's Health for the Philadelphia Inquirer

Michael Siegel: The Rest of the Story: Tobacco News Analysis and Commentary

Thomy Tonia: International Journal of Public Health-Blog 

1. How much time do you dedicate to your blog per day/week/month?

Jim: I wish I could post more blogs per week; right now I'm averaging about a post a week (sometimes it'll be 3-4 posts in a week, sometimes no posts for a few weeks in a row). Each post takes about an hour between research, linking and writing. And I've got to be constantly on the lookout for new and time-relevant material.

Elana: When I was writing weekly, I spent 3-5 hours a week researching, writing, editing, and posting (using the content management software, sometimes the hardest part!). I have a background in journalism, so I'm able to write and self-edit relatively quickly. Now that I'm posting only once a month, I probably spend 5-7 hours a month between culling through stories of interest, thinking about the relevance of various topics, writing, editing, and posting. It's actually more challenging to post only once a month, as I get out of practice and have more material to comb through to see what rises to the top.

Jonathan: On average, a 500-750 word post takes me 4-5 hours. I currently post twice a month. I used to post weekly, but the time burden was too much. 

Michael: Approximately one hour per day, mostly devoted to writing my daily posts.

Thomy: I blog as part of my job as an Editorial Assistant/ Social Media Editor for the International Journal of Public Health. When I was focused only on the blog, I dedicated about 4 hours per week (divided between blogging and visiting other blogs/public health sites- to get ideas, keep informed and interact). Since I now also manage the twitter and Facebook accounts, I have reduced my blog time to 2-3 hours per week. 

Leah: I spend about 5 hours on each blog post- between finding the story, writing, and marketing the posts on social media. Since I try to address topics that are hot in the news that week or that day (like Jim says above), I'm constantly on the lookout for relevant stories.  Throughout the week I save all my possible stories/links/ideas on a spreadsheet and pick the best one.  While my posting frequency has varied over the past three years of writing Pop Health, my goal is to post at least once per week.

2. Who is the audience for your blog?

Jim: The blogs that I write are written for professionals in the fields of public health and emergency management. My thought is that I can affect more change by finding and teaching best practices to the people on the ground actually working with the public.

Elana: My blog is read by mental health and public health professionals as well as laypeople interested in psychology, mental health, pop culture, and suicide prevention. Since I blog on a site that does a lot of promotion for itself, I have a relatively wide readership. Each post can generate 500-2000 hits; I haven't done any real numbers-running, but 100-300 hits on the day the post is published is probably average, and then each post accrues hits over time.

Jonathan: The general public in Philadelphia and surrounding areas. Given the size of the health care sector in the region, I like to think health professionals read it as well. I also dream that policy makers read it—although I’m not sure if either health professionals or policy makers read Philly.com.

Michael: Incredibly diverse audience of anti-smoking advocates, groups, and researchers, smokers’ rights advocates, government agencies, tobacco companies, newspaper reporters, stock market analysts, consumers, trade groups, and policy makers.

Thomy: Originally, our intended audience was mainly public health students, as we are affiliated with the Swiss School of Public Health. However, especially through social media, our audience seems to be not only public health students and professionals but also people who just have an interest in public health. Nevertheless, it is not easy to know exactly who our audience is, as we do not get a lot of comments and it is difficult to know who actually reads the blog. We try to engage people to write guest posts for us. This generally works quite well.

Leah: I write for a broad public audience with an interest in public health, pop culture, or both. Therefore, I use it as a platform to breakdown and explain public health/communication concepts (e.g., "teachable moments"; "cue to action"). From the analytics, emails, and comments that I receive, I know that I have a large following among public health professionals, students, and teachers.  I have heard from more than one faculty member to say that they use my blog with their students to demonstrate the connection between public health and their everyday lives (e.g., movies, magazines, advertising).

3. What is the ideal “return/s on investment” for your blogging efforts? 

Jim: I've been writing blogs relevant to public health and emergencies for more than six years. I've found it to be one of the best investments I've made in my career, even with the huge investment in time and effort required for success.  I've found that the best return I've realized is my network of contacts and friends across the country and around the world; none of whom I would've met without being available and "out there" online.

Elana: For me, the ideal return on investment is reader engagement. I really get a lot out of seeing reader comments (the good and the not-so-good) and corresponding with readers via the comments section, or with friends and more personal connections on Facebook when I promote my posts there.

Jonathan: The ideal return is three-fold: (1) A public which understands that health is about more than just individual choices. A public which begins to see the reverberating impacts of social/economic policies, beyond the health care sector, on people’s health. A public which is knowledgeable about trauma theory and research on trauma/stress. (2) Networking. (3) Increased readership. While this is the most measurable, I’m not convinced it means all that much. Who’s reading? How are they reading? How is the information changing their perceptions? Is it at all? We have no idea.

Michael: The ideal “return on investment” is the blog having an actual impact on public policy.

Thomy: Increasing readership and dissemination of ideas is always a good return. We would ideally like to have more engagement in the form of interaction (e.g., comments). Networking is also quite satisfying and really helps broaden our blogging horizons. As a public health journal, we are also interested in disseminating our research articles.  I personally would like to see more and more public health students, researchers and professionals having blogs and engaging in social media to learn new things, disseminate their knowledge, “meet” interesting people and also –why not- for the fun of it!

Leah: Pop Health began as a hobby that just happened to incorporate my field of public health.  Now it has become a key part of my professional portfolio.  Therefore, the key returns are now different than three years ago.  Now, I'm looking for increased readership and referrals to my site.  I'm looking for increased dialogue with readers and colleagues.  I'm also looking for new and exciting professional opportunities (e.g., guest blogging, writing, and teaching) that can emerge by branding my expertise in this niche of public health.

4. Do you measure these “returns”?  If so- how?

Jim: I've seen a tremendous benefit professionally. As a direct result of my online identity and interactions, I've been invited to more than a dozen international, national and regional conferences to speak on those topics I blog about.  But even beyond those personal returns, I've seen a tremendous benefit professionally. Not only am I able to call on friends I've made around the globe to help with ideas for work, but I've grown as a result of being forced to flesh out my ideas. When I write about something, I want it to be well thought-out and considered. By writing these ideas out, I am forced to consider not only my idea, but how it affects other, larger problems...Without writing it out, I would just have a nugget of an idea, no more than that.

Elana: I measure this ROI very unscientifically. I notice which topics generate more interest (both in terms of hits, which are tracked by Psychology Today, and comments) either on the Psychology Today site or on Facebook. I've wanted to get more sophisticated with Google Analytics, but can't do that as I don't actually manage the website that hosts my blog. I've also enjoyed meeting people at professional conferences who recognized my name because of my blog. That really blew me away - it meant that I was really reaching people (not just my Mom!).

Jonathan: Philly.com tracks usage statistics and sends them to us on a weekly basis. Posts on animals, kids, and pop culture typically do the best.

Michael: Yes, but not formally. I assess the actions of public health agencies and organizations to determine whether the blog seems to be changing their thinking about these issues. I also assess the state of public opinion in the field regarding these issues.

Thomy: We keep track of visitors, time spent on blog (etc.) via Google Analytics and StatCounter. We also monitor the most popular posts and try to have some ongoing themes corresponding to these popular posts.  Regarding the “return on investment” to the Journal, we are trying to monitor whether articles that have been featured in the blog are downloaded more often from our website.

Leah: I have used Google Analytics and Blogger Statistics for measurements like page views, referring sites, and key words used to find Pop Health. I also take note of the posts that stimulate more engagement with readers- I would note that more dialogue seems to take place directly on social media where I market the posts (i.e., Facebook & Twitter) vs. the comment section on the blog itself.  As a result of the blog, I have also been invited to guest write on other sites like The Public's Health- so tracking those opportunities helps me to measure return on investment as well.

Evaluation and Return on Investment are key concepts in public health

With public health professionals constantly being asked to do more with less, it is imperative that we show how our investments are paying off. It is important to think of "investments" broadly- they are not just money...they are our time too.  As you can see from the responses to question #1, creating and maintaining a blog is a huge commitment.  And although we write for a variety of audiences with different goals (ranging from promoting research to trying to impact policy), we share the challenge of trying to evaluate those goals.

Therefore, we need to lead ongoing dialogue about the goals and evaluation of public health blogs. CDC's National Prevention Information Network (NPIN) is continuing its "In the Know: Social Media for Public Health" webcasts this spring and the June 4, 2013 event will focus on Measurement & Evaluation.  I look forward to continuing this discussion there and elsewhere.

Thank you again to Jim, Elana, Jonathan, Michael, and Thomy for your contributions!  I appreciate you making the time and sharing your experiences.

I would like to invite other public health bloggers to weigh in on these questions:  

• How much time do you dedicate to your blog per day/week/month?
• Who is the audience for your blog?
• What is the ideal “return/s on investment” for your blogging efforts? 
• Do you measure these “returns”?  If so- how?

A Pop Health Book Review of “In the Kingdom of the Sick: A Social History of Chronic Illness in America”

In 2009 I read "Life Disrupted: Getting Real about Chronic Illness in Your Twenties And Thirties".  Since the book inspired me personally and professionally, I was delighted that Twitter enabled me to connect directly with the author Laurie Edwards.  I was even more delighted when she asked to interview me for her new book, "In the Kingdom of the Sick: A Social History of Chronic Illness in America".  Since Pop Health focuses on health communication and the coverage of public health issues in the media, we had plenty of mutual interests to discuss!

"The very nature of chronic illness- debilitating symptoms, physical side effects of medications, the gradual slowing down as diseases progress- is antithetical to the cult of improvement and enhancement that so permeates pop culture." 
("In the Kingdom of the Sick", page 34)

Early in the book, I found this quote incredibly powerful.  It is true.  Our society values and spotlights those that overcome adversity- those that inspire us- those that beat the odds.  Before his fall from grace, we can all remember the worldwide cheering for Oscar Pistorius- making history last summer for being the first double-amputee to compete in the Olympic games.  Edwards highlights those societal values in her book by drawing on the imagery found in many commercials for breast cancer research and fundraising.  Those commercials show an unforgettable image, a "cancer survivor triumphantly crossing the finish line in her local fund-raising event surrounded by earnest supporters."  That triumphant image is a far cry from what Edwards and colleagues term the "Tired Girls" (i.e., female patients suffering with "invisible illnesses" like fibromyalgia, chronic fatigue syndrome, and migraines).  "The Tired Girl stands for so much that society disdains:  weakness, exhaustion, dependence, unreliability, and the inability to get better" (page 103).

The good news is that many of the "Tired Girls" (and Guys) are getting connected and getting empowered.  Edwards dedicates a significant portion of her book to the discussion of "patients in the digital age."  She describes the emergence of "e-patients" (those that are empowered, engaged, equipped, enabled) and how they are using technology to actively participate in the development of their care plans, connect with patients with similar diagnoses, give voice to their experiences, advocate for policy change, and debate controversial topics like vaccinations.

As a public health professional with significant interest in health communication, I was fascinated by a recurring theme that Edwards highlights from these conversations among empowered patients and writers:

"How does language influence the illness experience?"          

The reader is led through an intriguing discussion of the use and implications of terms such as:

• Illness vs. Disease
• Illness vs. Chronic Condition
• Illness vs. Disability
• Military Metaphors (e.g., "the battle against disease")
• Chronic Pain Patient vs. Patient with Chronic Pain
• Healthy Disabled vs. Unhealthy Disabled
• Patient (does it connote passivity?)

"In the Kingdom of the Sick" is a fascinating read for anyone with a personal and/or professional connection to chronic illness.  It begins by giving you a strong foundation in the history of illness, research, and patient advocacy movements.  It then challenges you to consider the impact of advances in patient rights, science, communication, and technology on the incidence, treatment, and perception of chronic illness.  I highly recommend this book to my Pop Health readers, friends, and colleagues.

If you are interested in connecting with Laurie Edwards:

Website:  http://www.laurieedwardswriter.com

Blog: http://www.laurieedwardswriter.com/blog

Facebook:  http://www.facebook.com/laurieedwardswriter

Twitter:  https://twitter.com/achronicdose 

"Girls" Tackles OCD: What I Hope IS NOT Happening In Our Emergency Departments

This afternoon I had the pleasure of having some downtime- so I used it to catch up on the three recent "Girls" episodes sitting on my DVR.  Having avoided spoilers, I was surprised and saddened to see Hannah (Lena Dunham) being consumed by Obsessive Compulsive Disorder (OCD).  We learn that she had a serious bout with the condition once before- in high school.  It was so serious that she sought professional help and medication at that time.  Flash forward to her post-college life and we see her plagued again...perhaps triggered by the stress of a recent break-up and a looming book deadline.

While there are several disturbing issues in the most recent episode "On All Fours" (you can see the comments in Alan Sepinwall's review for those details), I want to focus specifically on Hannah's trip to the local emergency department (ED).

I was very upset watching this scene and I'll tell you why:

We know that emergency room providers are key gatekeepers for those who are suicidal and/or suffering from mental illness.  Research tells us that 1 in 10 suicides are by people seen in an emergency department within 2 months of dying.  Acknowledging the importance of this gatekeeper role, leadership organizations in suicide prevention have created a variety of toolkits and resources to educate and train emergency department personnel to identify patient warning signs and assess their risk.

In "On All Fours", Hannah visits the ED after obsessively sticking a Q-tip in her ear, getting it stuck, and experiencing pain.  After lying to her parents by saying she has "12-15 good friends" to accompany her to the ED, she goes alone.  The scene opens with the doctor telling her, "Well, you must be feeling pretty silly."

As the doctor examines her injured ear, Hannah says:

"I've just been having a little trouble with my mental state."
"I have a lot of anxiety and I didn't think stress was affecting me but it actually is."
"I'm not saying this was an accident, but I was just trying to clean myself out."

At no point does the doctor respond to any of these statements.  He is all business, telling her to follow-up with a specialist if she is still experiencing pain in a few days.  As Hannah lays down so he can put antibiotic drops in her ear, she pleads with him to look at her other ear.  He snaps at her "there is nothing wrong with the other one."  Hannah cries on the bed because it (the drops? her situation?) hurts so bad.

He discharges her and she walks home alone.  In just a t-shirt and no pants.

Now I'm not saying that Hannah was acutely suicidal or verbalized such a threat in the ED.  However, I am saying that she made several clear statements about her mental health that should have been treated with concern and respect by a competent medical provider.  Her demeanor and her appearance deserved a kind ear, a social worker's visit, someone to ask if she was all right.

These recent episodes have been applauded for their accurate portrayal of OCD.  I hope that a future episode will show a portrayal of a caring and skilled provider using the public health prevention and education tools that are available to assist someone in desperate need of help.

For any readers that may need help:

• The National Suicide Prevention Lifeline:  1800-273-TALK
• Substance Abuse & Mental Health Services Administration: (SAMHSA) Mental Health Treatment Finder

Using Twitter to Track Disease: Weighing the Advantages and Challenges

A few weeks ago I participated in a fantastic twitter chat on the use of social media for public health.  During the event, our moderators posed the following question: "Are there any other diseases (besides the flu) that we could track on social media?"

The question generated a very lively discussion that I was inspired to revisit on Storify this morning after reading the Washington Post's article, "Twitter becomes a tool for tracking flu epidemics and other public health issues." 

The WP article highlights several advantages and challenges of monitoring public health diseases and/or conditions on twitter.  My twitter chat colleagues brought up many other important issues for us to consider, so I'm including these expanded lists:

Advantages:

• Offers real time data on health or behavior (Government data can often take weeks or months to be released)
• There is so much available data! 
• It could capture cases that would not otherwise be formally documented at a physician's office or hospital.
• It has proved helpful in tracking time sensitive disease outbreaks (e.g., Novovirus).  *Check out this article about how twitter was used to track Norovirus activity during a journalism conference.

Challenges:

• Accuracy and case definition (i.e., does a twitter user really have the flu or just a bad cold?)
• Tracking specific words like "sick" or "flu" can bring up a lot of content that is unrelated to the twitter user being ill themselves (e.g., "I'm so sick of this terrible weather").  *Check out how Johns Hopkins researchers are working to address this problem by better screening tweets.
• We must differentiate between tracking symptoms vs. tracking cases- they are not the same.
• Our search strategies should include various terms or slang that are used to describe the disease or behavior of interest.
• Caution: media coverage of certain illnesses can cause a spike in key words on twitter without a rise in actual cases.
• What are the privacy concerns?
• Twitter might not thoroughly capture diseases or conditions that carry stigma (e.g., mental illness) because users may be hesitant to discuss them in a public forum.
• Results could be skewed by populations who are over or under represented on twitter.
• Do we need to train "trackers" to intervene? E.g., what if they are monitoring dangerous tweets/behaviors like suicidal ideation and attempts?

While the challenges list is quite long, I hope we are not discouraged!  I think twitter is an enormous resource for public health professionals.  We just need to be thoughtful and thorough regarding how to use twitter effectively.

More Resources:

The Washington Post article and related stories shared great links to more information about research in this area:

• YouTube video on University of Rochester efforts to track influenza on twitter.  It also describes their related app: Germ Tracker (warning: it may have you hopping off your regular morning bus). 
• Johns Hopkins University article: "You Are What You Tweet: Analyzing Twitter for Public Health".
• Brigham Young University article: "'Right Time, Right Place' Health Communication on Twitter: Value and Accuracy of Location Information".
• A great article that highlights what we can learn from Google Flu (since their predictions were off this year)- emphasizes the importance of "re-calibrating" your models or algorithms each year.

What Do You Think?

• What other advantages and/or challenges should we add to the list?
• What other resources can you share?

  

Seth MacFarlane: An Oscar Host who is Harmful to Comedy and the Public’s Health

This week’s post for Pop Health was co-written by Beth Grampetro, MPH, CHES. Beth has been working in college health promotion for 7 years and her interests include feminism online and in popular culture. You can follow her on twitter @bethg24. 

The role of society is important in public health.  Health is not just influenced by individual decisions and behaviors.  It is also influenced by our interactions with the world around us- our communities, our families, our workplaces, our schools, entertainment, celebrities, and the media.  These interactions can have a very strong influence (good or bad) on the public’s health.

With that in mind, we were horrified to witness host Seth MacFarlane’s monologue and ongoing commentary during Sunday night’s Oscars.  According to Nielsen ratings, approximately 40.3 million viewers tuned in to the Oscar telecast.  This broad audience watched MacFarlane, a widely known celebrity, make jokes about domestic violence, female actresses’ bodies, and various forms of discrimination.

In the opening number, MacFarlane sang a song entitled “We Saw Your Boobs”, about the scenes in various movies where actresses in the audience had appeared topless. While it has been reported that the actresses were in on the joke, it is nonetheless disturbing that this number passed muster- especially given that several of the scenes he referenced were from movies where the actresses he named portrayed rape victims.

Other jokes included a reference to Jennifer Aniston’s past as a stripper, a congratulatory statement about how great all the actresses who “gave themselves the flu” to lose weight looked in their dresses, and a comment about how Latino actors (in this case Javier Bardem, Salma Hayek, and Penelope Cruz) have difficult-to-understand accents “but we don’t care because they’re so attractive.”

MacFarlane also tried some jokes that had men as their targets but still managed to get mud on a few women in the process. He joked that Rex Reed was going to review Adele’s performance (a reference to Reed’s recent movie review in which he called Melissa McCarthy a “hippo”) and made a joke about 9-year-old nominee Quvenzhané Wallis dating George Clooney. Some defenders of MacFarlane’s performance argued that these jokes were meant to be about the men in question, but ignored the fact that they were made at the expense of women and girls.

The Oscars are billed as “Hollywood’s Biggest Night”, and it’s incredibly disappointing to see what is the biggest event for the entertainment industry turned into the worst office party in history, complete with a leering coworker who’s creating a hostile environment.  If MacFarlane succeeded at anything, it was reminding women that they’re expected to always be thin, be pretty, and be willing to shut up and take it, lest they spoil the whole evening.

There is evidence to show that (unfortunately) these types of jokes and messages that devalue women are believed and internalized within our communities.  For example, a 2009 study by the Boston Public Health Commission found that over half of teens surveyed blamed the singer Rihanna after she was beaten by her boyfriend Chris Brown.  In addition, research shows that a mere 3-5 minutes of listening to, or engaging in, fat talk can lead some women to feel bad about their appearance and experience heightened levels of body dissatisfaction.

Research also tells us that these internalized messages and social norms are correlated with serious public health outcomes.  For example, the CDC outlines the risk factors for sexual violence perpetration.  Under society level factors we find (among others):

• Societal norms that support sexual violence
• Societal norms that support male superiority and sexual entitlement
• Societal norms that maintain women's inferiority and sexual submissiveness
• Weak laws and policies related to gender equity

So the issue is much bigger than if Seth MacFarlane was funny or made a good Oscar host.  The issue is about the quality of the role models we choose to represent our communities and the messages they send.  These messages can have a broad and long lasting influence on public health.  We hope the Academy will choose wisely next year.

Downton Abbey: A Mountain of Viewer Tears Leads to an Incredible Online Discussion about Maternal Health

Warning: if the January 27, 2013 episode of Downton is still on your DVR- this post contains spoilers!

From the looks of twitter this week, I am not the only person who was devastated by the loss of Lady Sybil on Downton Abbey.  She died of Eclampsia shortly after giving birth to her daughter.  In my house, there was complete silence while we watched Sybil convulsing and struggling to breathe.  After she died, our horror and sadness quickly turned to anger.  There were two doctors in the room (one of whom made the correct diagnosis)- how could this happen?

As I contemplated this question, I was fascinated to see how this story line impacted the public health messaging that started appearing on twitter.  I recognized a few trends:

Making the connection to current women's health issues and debates

There has been much concern about men making decisions about women's healthcare- for example, the comments in 2012 about the definition of rape and the ongoing abortion debate.  Since Sybil's death was largely the result of poor decisions about her health (made by her father and the fancy male doctor consulting on her case), I saw the following post on this topic over and over again:

 

Identifying a Teachable Moment:  Preeclampsia and Eclampsia Specifically

Like many organizations, the American Public Health Association (APHA) followed up on Monday with this message:

Identifying a Teachable Moment:  Maternal Mortality and Maternal Health Broadly  

I saw many links to organizations such as Every Mother Counts, which focuses on global maternal health advocacy:

In addition to the discussion on social media, many news outlets and foundations also took the opportunity to post information on their websites about the condition that killed Sybil.  For example, ABCNews wrote, "Eclampsia Death in 'Downton Abbey' Highlights Pregnancy's No. 1 Killer".

I would love to see some evaluation data to follow this teachable moment.  Some questions that I have:

• How many people searched for Preeclampsia and Eclampsia following the episode?  (As a side note, this episode aired months ago in the UK- was there a similar searching pattern?)
• How many physicians/midwives/clinicians received inquiries from patients following the episode?
• Beyond knowledge- did this episode change any clinician behaviors?  Did they go back and review a suspicious case after seeing a reminder of the severity of this condition?  Did they perform a more comprehensive screening?

What do you think?

What other evaluation questions should we be asking?

What other trends did you see in the discussion on social media (or in person) following this episode?

Pop Health is Named One of the Top 25 Public Health Blogs of 2012!

Many thanks to MPHonline for naming Pop Health one of the top 25 public health blogs of 2012.  About Pop Health they write:

"A unique blog focusing on the intersection of pop culture and public health. Written by an experienced public health educator with an MPH, a special interest in health communication and the affect of media coverage on public health issues, and great wit, there really isn’t anything else like it out there".

Check out the full list of blogs on the MPHonline website.

Facebook Revisited: Does the Platform Help or Hurt Users (or Both)?

The benefits and challenges of social media for public health are a frequent topic on Pop Health.  For example, I've explored the influence of these platforms on emergency response, increasing the number of organ donors, and health activism.  However, one of the debates that I hear the most among public health colleagues relates to Facebook.

Does it isolate users?  Does it connect users?  Does it do both?

Earlier this year, my colleague Elana Premack Sandler explored this debate as it relates to loneliness.  Inspired by a feature in the Atlantic Magazine, Elana asks key questions like, "Is Facebook part of the separating or part of the congregating?"  She also mentions concerns about how Facebook (and other social media platforms) affect our social skills and therefore our friendships.

I thought of Elana's writing as I read a new post on the Atlantic website today, "Are Your Facebook Friends Stressing You Out?  (Yes.)".  This post highlights a new report out from the University of Edinburgh Business School.  The report caught my eye because it identified a very specific cause of stress for Facebook users.  The more groups of "friends" a user had (e.g., family, real life friends, co-workers, etc), the more anxiety they had because there was a greater chance of offending someone with their posts.  The report stated that the greatest anxiety came from adding parents or employers as Facebook "friends".  As Megan Garber writes so eloquently in her Atlantic post, the stress comes from Facebook forcing users to "conduct our digital lives with singular identities".  The way we speak or act around family or friends or co-workers must jive on Facebook, or we run the risk of offending someone.  I'm sure many of us saw this conflict a few weeks ago when political and election posts ran rampant on Facebook!

The anxiety described above is interesting, because ideally what we would hope is that Facebook provides a source of social support to users.  Social support occurs when one is cared for by others (via emotional, tangible, or informational support).  The presence or absence of social support is a factor related to public health issues, such as suicide.    

So after reading through the various posts/articles, what do I think about my opening questions about Facebook?

Does it isolate users?  Does it connect users?  Does it do both?

I think it does both.  I have seen it do both.  For example:

Isolation:  I have spoken to friends and colleagues who feel terrible about themselves or their lives after scrolling through their Facebook news feed.  A friend with chronic illness feels isolated hearing about the latest vacation or new job taken by her "friends".  A friend suffering from infertility can't bear one more picture of a "friend" and their newborn.  I think much of this results from the "whitewash" that many of us put on Facebook.  We often paint a picture for our Facebook friends, full of engagements and babies and fun events.  

Connection:  Earlier this year I watched a suicide intervention unfold on Facebook via the comment section under a post.  A friend of a friend posted a suicidal message on their Facebook wall.  Within minutes, "friends" reached out in the comments.  However, not only did they "speak" to the person, but they interacted with each other and followed up in real life.  One comment read, "Did someone go to his house?"  The next comment read, "I went to his house and I called his parents".  After he was taken to the hospital, a comment was posted to inform all the friends that he was safe.  As a public health practitioner that worked in suicide prevention for years, I was amazed with what I saw. 

So what can we do to reduce the isolation/anxiety and increase the connection?  You can certainly start by exerting your control over your Facebook account.  For example:

• Create a policy about "groups of friends" that you accept into your circle.  I know lots of people that do not accept requests from co-workers or parents.  They make it clear to the individual that it is nothing personal, they just have minimal friends with which they share intimate information.
• Use the privacy settings!  You can control who can see your posts.
• Find and use the unfriend button!  I have done this frequently.  If someone posts messages that are offensive or disrespectful regarding something that I've posted- I get rid of them quickly.
• Take a break from Facebook.  If you realize that Facebook is making you feel bad about yourself, take a break or disable your account.  Use that time to connect with your in real life (IRL) friends or family.

Tell me what you think!  

• Does Facebook isolate and stress us?  
• Does Facebook connect us?
• What other strategies can help to reduce the isolation and increase the connection on Facebook or other social media platforms?

A Superstorm of Social Media

Over the past week, there has been widespread discussion regarding the broad reach and value of social media during Superstorm Sandy.  Jim Garrow wrote about the emergency management field's adoption of social media and the powerful influx of images received through those channels.  In the New York Times, Brian Stelter and Jennifer Preston discussed how public officials use social media during a crisis.  Technology bloggers have posted analyses regarding the increase in internet use during the storm.

So what can Pop Health add?  I wanted to break down "social media use" even further.  I wanted to discuss the specific ways in which I saw it being used.  And although I think we all have a primarily positive view of social media's contribution during an emergency, I think it is also important to highlight some of the challenges that may appear with these communication channels.

Let's start with the good stuff!  During and after the storm, I saw social media being used for:

Individual-Level Advocacy

Affected residents used social media to communicate directly with local and state officials to report property damage, ask questions, and request direct assistance.  For example:

• As the screen shot above shows, Cory Booker (the Mayor of Newark, NJ) has been corresponding directly with his residents on twitter and following up with the necessary supplies or services.

• Locally in Philadelphia, I've seen the same thing with Mayor Michael Nutter.  He has been messaging with citizens about downed trees and power, in order to direct assistance to areas that need it the most.

Community-Level Advocacy

One thing that amazed me during Sandy was the power of social media in terms of advocacy on behalf of whole communities (whether they be particular neighborhoods or cities).

• When Margate, Longport, and Brigantine, NJ were reopened after the storm, there was immediate and overwhelming protest to the toll on the Margate bridge.  Residents felt that it was extremely insensitive (and selfish) for the bridge owners to charge storm refugees to get back onto the island (especially when they had no choice but to take that particular route).  Through protests on twitter and Facebook, the bridge owners were persuaded to reverse their decision to charge.

• The decision to cancel the NYC marathon was a difficult- and some would say delayed- decision.  While objections to the marathon (and the resources it would require) were widespread, much of the discussion happened on social media.  These channels were used to post online petitions and plan protests.  As you know, the race was finally canceled two days before the start.

Donations

Social media has been a key place to ask for donations to help the victims of Sandy.  Some strategies have been more traditional (e.g., asking for donations for the Red Cross).  Others have been quite creative!

• For example, runners in the canceled NYC marathon could follow a link posted on twitter in order to donate their hotel room to someone displaced by the storm.

The power of social media lies in its reach and ability to deliver information in real time.  On the flip side, the concern is that false information can spread quickly as well.  Here are a few examples that happened during Sandy:

• If you were using social media when the storm hit, you may remember seeing many unbelievable images.  One that I saw over and over was a group of soldiers guarding the Tomb of the Unknown Soldier.  However, we later learned that this image was taken back in September.  Mashable pulled together a list of "7 Fake Hurricane Sandy Photos You're Sharing on Social Media".  

• A congressional campaign manager in NYC resigned after sending out false information on twitter.  One of the rumors he started was that the trading floor of the New York Stock Exchange had 3 feet of flood water.  Many of his tweets are shown here.

As you can imagine, there is great danger to the public's health if incorrect information is widely shared.  Residents may panic and evacuate from a location that is actually safe.  Emergency management and public officials may be distracted from the work at hand, because they have to deal with clarifying a rampant and destructive rumor.

I think we can all agree that the value of social media in a crisis far outweighs the potential challenges.  However, this is an important conversation to keep having and I'd like to hear from you:

• In addition to the examples above, how did you see social media used during Sandy?
• How can we be even more innovative?  In what ways could we use social media during a crisis that we haven't yet tried?
• How can we prevent false information from spreading during a crisis?

October is [Fill in the Blank] Awareness Month- A Guest Post for "The Public's Health"

Today I had the pleasure contributing another guest post on "The Public's Health".  The blog is a collaboration between the Drexel University School of Public Health and Philly.com.  In multiple posts each week, the authors highlight contemporary, historical, and ethical matters that challenge public health professionals.

In today's post, I examine health "awareness campaigns" and discuss their effectiveness for improving public health.

What do you think:  Is the public burned out on annual health observances? Or are they effective in helping to prevent illness/disease? In what other ways can organizations and individuals become more action-oriented to help improve the public’s health?

Madonna's "MDNA Show Manifesto" Defends Using Guns on Tour: Do You Agree?

As we speak, Madonna is en route to my city- Philadelphia, to launch the North American leg of her "MDNA World Tour".  In advance of her arrival, she has released a statement to the local Metro defending one of the most controversial parts of her tour...the use of fake firearms in concert.  Here is a portion of that statement:

"It's true there is a lot of violence in the beginning of the show and sometimes the use of fake guns - but they are used as metaphors.  I do not condone violence or the use of guns.  Rather they are symbols of wanting to appear strong and wanting to find a way to stop feelings  that I find hurtful or damaging.   In my case its wanting to stop the lies and hypocrisy of the church,  the intolerance of many narrow minded cultures and societies I have experienced throughout my life and in some cases  the pain I have felt from having my heart broken".

Gun violence is (unfortunately) not a new problem.  However, the topic is quite timely due to increased U.S. media coverage following several mass shootings in the past few weeks- Aurora, CO, Oak Creek, WI, and New York, NY.  The issue of gun violence has reached crisis levels in Philadelphia where Madonna will be performing.  A new open source journalism project called http://guncrisis.org/ "contends that there is an epidemic of homicide by gunfire in Philadelphia and similar cities".  They are seeking solutions.

The solutions being sought by GunCrisis: Philadelphia and others involve taking a public health approach to gun violence.  The recent high profile shootings have produced several well-written pieces about gun violence and what we need to do next:

•  Prompt policy discussions about easy access to ammunition, high-capacity magazines, and assault weapons.
• Use our public health skills to conduct further research into the causes of firearm injuries.
• Examine gun violence as a social disease- one that stems from a society "saturated with guns".

Tell me what you think:

Do you believe that the gun "saturation" goes beyond those in our homes to include those used for entertainment?  E.g., Guns in movies or video games; Madonna's concert props

Is Madonna successful? Does using guns as a metaphorical image help her reach her goals and battle against hypocrisy and intolerance?

In addition to those listed above, what other strategies should we incorporate into a public health approach against gun violence?

Cameron Diaz: The Next Celebrity Nutritionist?

Cameron Diaz is busy with her next project.  Her rep confirms her interest in writing a nutrition book to help young girls.  She wants to use her celebrity for good- to encourage girls not to fixate on being thin but instead just to make healthy choices.

A few thoughts:

Of all the celebrities that I see pitching these types of projects (I'm looking at you Gwyneth Paltrow), Cameron actually seems to model a healthy lifestyle.  She is not too thin, but instead looks muscular and strong.  We always see her keeping active with surfing and regular gym workouts.

It is reported that (in preparation for the book) Cameron will be visiting high schools to talk to teenagers about their food choices and what is important to them.  She wants to get their input, e.g., how do they decide what to eat? Although this work will not be a formal "Needs Assessment", I like that Cameron will be out in the community and talking to the teenagers who are the focus of her book.  Doing formative work before a project that engages your audience is incredibly important in public health.  Hearing and seeing what the health problem/s look like first hand allow us to craft more effective interventions.  So I applaud Cameron for planning to do this outreach versus just planning to write a book that may or may not address the challenges faced out in communities. For example, Cameron can discuss the importance of choosing fruit over potato chips, but if a teenager does not have access to affordable fresh fruit in their neighborhood, then the recommendation is not helpful.

One challenge to this effort is that even though Cameron appears to model a healthy lifestyle, she is still a member of the Hollywood community that has contributed to setting an unrealistic standard for beauty.  We have seen her on numerous magazine covers looking very thin and of course airbrushed.  In public health, we always have to think- "is this the right spokesperson"?  It is important to know how teenage girls view Cameron.  Do they see her as part of the problem?  Or part of the solution?

Another challenge is that (from my perspective), celebrity "nutritionists" do not have the best track record for safety and accuracy.  Take Cameron's friend Gwyneth Paltrow.  She has regularly promoted nutrition strategies like detox cleanses and gluten-free diets.  Her extreme choices do not send a message of moderation to teenage girls.  In addition, Gwyneth's cover photos also contribute to the unrealistic standard for beauty.

As I've discussed many times on this blog, celebrities can be an incredible resource for public health.  They have a visible platform and extensive reach to many of our audiences.  However, that can work for us or against us based on the accuracy and relevancy of their messages.  It is imperative that they work closely with clinicians (e.g., physicians, nutritionists) and public health practitioners to craft the messages and design outreach programs.

What do you think about Cameron writing a nutrition book?