David Satcher

The Surgeon General's Call to Action to Promote Sexual Health and Responsible Sexual Behavior

Abstract I am introducing the Surgeon Generals Call to Action to Promote Sexual Health and Responsible Sexual Behavior because we, as a nation, must address the significant public health challenges regarding the sexual health of our citizens. In recognition of these challenges, promoting responsible sexual behavior is included among the Surgeon General—s public health priorities and is also one of the Healthy People 2010 Ten Leading Health Indicators for the Nation. Although it is important to acknowledge the many positive aspects of sexuality, we also need to understand that there are undesirable consequences as well—alarmingly high levels of sexually transmitted disease and HIV/AIDS infection, unintended pregnancy, abortion, sexual dysfunction, and sexual violence. These challenges can be met, but first we must find common ground and reach consensus on some important problems and their possible solutions. It is necessary to appreciate what sexual health is, that it is connected with both physical and mental health, and that it is important throughout the entire life span, not just the reproductive years. It is also important to recognize the responsibilities that individuals and communities have in protecting sexual health. The responsibility of well-informed adults as educators and role models for their children cannot be overstated. Issues around sexuality can be difficult to discuss—because they are personal and because there is great diversity in how they are perceived and approached. Yet, they greatly impact public health and, thus, it is time to begin that discussion and, to that end, this Surgeon General—s Call to Action is offered as a framework. During its development we received a wide range of input and have identified several areas of common ground. A major responsibility of the Surgeon General is to provide the best available science based information to the American people to assist in protecting and advancing the health and safety of our nation. This report represents another effort to meet that responsibility.

The Public Health Approach to Eliminating Disparities in Health

Reducing and eliminating disparities in health is a matter of life and death. Each year in the United States, thousands of individuals die unnecessarily from easily preventable diseases and conditions. It is critical that we approach this problem from a broad public health perspective, attacking all of the determinants of health: access to care, behavior, social and physical environments, and overriding policies of universal access to care, physical education in schools, and restricted exposure to toxic substances. We describe the historical background for recognizing and addressing disparities in health, various factors that contribute to disparities, how the public health approach addresses such challenges, and two successful programs that apply the public health approach to reducing disparities in health. Public health leaders must advocate for public health solutions to eliminate disparities in health.Reducing and eliminating disparities in health is a matter of life and death. Each year in the United States, thousands of individuals die unnecessarily from easily preventable diseases and conditions. It is critical that we approach this problem from a broad public health perspective, attacking all of the determinants of health: access to care, behavior, social and physical environments, and overriding policies of universal access to care, physical education in schools, and restricted exposure to toxic substances. We describe the historical background for recognizing and addressing disparities in health, various factors that contribute to disparities, how the public health approach addresses such challenges, and two successful programs that apply the public health approach to reducing disparities in health. Public health leaders must advocate for public health solutions to eliminate disparities in health.

Unequal weight: equity oriented policy responses to the global obesity epidemic

The health professions need to spearhead a concerted intersectoral response to obesity, say Sharon Friel, Mickey Chopra, and David Satcher

Disparities in Antidepressant Treatment in Medicaid Elderly Diagnosed with Depression

Objectives: To determine whether there were racial or ethnic disparities in the use of antidepressants in low‐income elderly patients insured by Medicaid.

Include a social determinants of health approach to reduce health inequities.

Reducing health disparities, primarily those based on race/ethnicity and gender, has long been a public health priority in the United States, but the first official goal to eliminate health disparities came with Healthy People 2010.1 Recent developments led by the World Health Organization (WHO), however, have accelerated the thinking about the causes of health inequities—i.e., disparities that are systematic, avoidable, and unjust2—and how best to address their reduction.3,4 The WHO Commission on Social Determinants of Health concluded in 2008 that the social conditions in which people are born, live, and work are the single most important determinant of ones health status.3 Certainly, individual choices are important, but factors in the social environment are what determine access to health services and influence lifestyle choices in the first place. In addition to the WHOs work, state and local health departments, national government agencies (such as the Centers for Disease Control and Prevention and other divisions of the Department of Health and Human Services in the U.S.), and other national organizations have recognized the need to address health inequities in a systematic way by addressing more than individual behavioral factors.5–12 This global movement recognizes that to reduce health inequities, it will be necessary to incorporate a social determinants of health approach with existing approaches. Social determinants are defined as follows: “… the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics.”13 Broadening our collective approaches to reducing health inequities by addressing the social and structural conditions needed for good health for all is urgently needed now. These social and structural conditions include education; housing; employment; living wages; access to health care; access to healthy foods and green spaces; justice; occupational safety; hopefulness; and freedom from racism, classism, sexism, and other forms of exclusion, marginalization, and discrimination based on social status. The inequitable distribution of these social conditions across groups contributes to persistent health inequities. While a social-determinants approach is important for people of all ages, it is critically valuable for children, whose positive early development can improve their health throughout the life span.14 As a former U.S. Surgeon General, I am committed to eliminating health disparities in the United States and providing care to vulnerable populations such as the indigent, foreign-born, and homeless. I urge a more broad-based and systematic approach to adequately address the health inequities that have been abundantly documented in the U.S. and which I have seen on a daily basis across the country. I call on people from all disciplines and sectors to come together and work toward achieving the Healthy People 2020 objectives, especially as they relate to social determinants of health. We need a new way of thinking, one where, as public health professionals, we lead by taking an interdisciplinary approach and collaborating across a wide range of disciplines, developing our own workforce to effectively address social determinants of health, and insisting health and non-health policies incorporate a social-determinants approach. We all have a role to play. The federal government should raise the profile of social determinants and communicate to the public what is meant by this somewhat unfamiliar approach. Public health and the work we do can be framed around health equity. Communities and local governments and organizations will have to be educated about the growing movement. Clear, concise language and concrete examples of how people can affect change will be needed. We should have “health in all policies” because nearly all social determinants are outside the direct control of the health sector. Although the goal of many social and economic policies may not be to affect health outcomes, the fact is they will.14 From funding opportunity announcements to accountability mechanisms, all facets of public health should include addressing social determinants. Our partnerships will have to be stronger if we are to have an impact. We must reach out to nontraditional partners in the private sector, industry, and other parts of government in the transportation, education, and justice sectors, for example. Analyses of equity effectiveness should be conducted alongside those of cost-effectiveness to ensure that the impact of various policies on health outcomes is given equal consideration.14,15 Finally, we must expand resources to address these underlying determinants. Public resources could be better leveraged and collaborations with the private sector and foundations should also be sought. In short, we must be proactive, collaborative, inclusive, and deliberate as we advance the use of a social-determinants approach to reducing health inequities among and between populations.

Triangulating on success: innovation, public health, medical care, and cause-specific US mortality rates over a half century (1950-2000).

To identify successes in improving Americas health, we identified disease categories that appeared on vital statistics lists of leading causes of death in the US adult population in either 1950 or 2000, and that experienced at least a 50% reduction in age-adjusted death rates from their peak level to their lowest point between 1950 and 2000. Of the 9 cause-of-death categories that achieved this 50% reduction, literature review suggests that 7 clearly required diffusion of new innovations through both public health and medical care channels. Our nations health success stories are consistent with a triangulation model of innovation plus public health plus medical care, even when the 3 sectors have worked more in parallel than in partnership.

The Potential for Elimination of Racial-Ethnic Disparities in HIV Treatment Initiation in the Medicaid Population among 14 Southern States

Objectives The purpose of this study was to explore the racial and ethnic disparities in initiation of antiretroviral treatment (ARV treatment or ART) among HIV-infected Medicaid enrollees 18–64 years of age in 14 southern states which have high prevalence of HIV/AIDS and high racial disparities in HIV treatment access and mortality. Methods We used Medicaid claims data from 2005 to 2007 for a retrospective cohort study. We compared frequency variances of HIV treatment uptake among persons of different racial- ethnic groups using univariate and multivariate methods. The unadjusted odds ratio was estimated through multinomial logistic regression. The multinomial logistic regression model was repeated with adjustment for multiple covariates. Results Of the 23,801 Medicaid enrollees who met criteria for initiation of ARV treatment, only one third (34.6%) received ART consistent with national guideline treatment protocols, and 21.5% received some ARV medication, but with sub-optimal treatment profiles. There was no significant difference in the proportion of people who received ARV treatment between black (35.8%) and non-Hispanic whites (35.7%), but Hispanic/Latino persons (26%) were significantly less likely to receive ARV treatment. Conclusions Overall ARV treatment levels for all segments of the population are less than optimal. Among the Medicaid population there are no racial HIV treatment disparities between Black and White persons living with HIV, which suggests the potential relevance of Medicaid to currently uninsured populations, and the potential to achieve similar levels of equality within Medicaid for Hispanic/Latino enrollees and other segments of the Medicaid population.

A comprehensive examination of the health knowledge, attitudes and behaviors of students attending historically black colleges and universities.

There is limited information about African American students attending Historically Black Colleges and Universities (HBCUs) in the areas of health behavior, health knowledge, and attitudes. To fill this gap, a comprehensive examination of first-year students was undertaken at a consortium of HBCUs. A non-random sample of 1,115 freshmen were administered a survey that assessed several domains including: (1) demographics, (2) general health, (3) smoking habits, (4) disease risk, (5) weight perception, (6) physical activity, (7) perceived stress, (8) eating habits, (9) social support, (10) personal/family medical history, (11) leadership, (12) domestic violence, (13) substance use, and (14) sexual behavior. In general, most students knew about health behaviors and disease risk. Areas that warrant further exploration include physical activity, sexual behavior, and drug use. The analyses provide key information for health education and prevention.

Toward Culturally Centered Integrative Care for Addressing Mental Health Disparities among Ethnic Minorities

Despite decades of research, recognition and treatment of mental illness and its comorbidities still remain a significant public health problem in the United States. Ethnic minorities are identified as a population that is vulnerable to mental health disparities and face unique challenges pertaining to mental health care. Psychiatric illness is associated with great physical, emotional, functional, and societal burden. The primary health care setting may be a promising venue for screening, assessment, and treatment of mental illnesses for ethnic minority populations. We propose a comprehensive, innovative, culturally centered integrated care model to address the complexities within the health care system, from the individual level, which includes provider and patient factors, to the system level, which includes practice culture and system functionality issues. Our multidisciplinary investigative team acknowledges the importance of providing culturally tailored integrative health care to holistically concentrate on physical, mental, emotional, and behavioral problems among ethnic minorities in a primary care setting. It is our intention that the proposed model will be useful for health practitioners, contribute to the reduction of mental health disparities, and promote better mental health and well-being for ethnic minority individuals, families, and communities.

Do Clinicians Screen Medicaid Patients for Syphilis or HIV When They Diagnose Other Sexually Transmitted Diseases

Background Patients diagnosed with gonorrhea or chlamydia are at high risk for HIV and syphilis, and should be offered screening for both. Goal This study measures HIV and syphilis screening rates among Medicaid patients diagnosed with another sexually transmitted disease (STD). Study Design Using 1998 Medicaid claims data from 4 states, we identified individuals diagnosed with gonorrhea, urogenital chlamydia, or pelvic inflammatory disease, and then measured the proportion receiving screening tests for HIV and syphilis. Results Only 25% of STD-diagnosed Medicaid patients received screening tests for syphilis and only 15% for HIV. We found significant state-to-state variability in screening rates. Conclusion Medicaid patients diagnosed with a nonbloodborne STD represent a high-risk group that is not adequately screened for syphilis and HIV despite repeated contact with medical professionals. Interventions should focus on eliminating missed opportunities for screening these high-risk individuals.