Viewing Scared Straight as a Public Health Failure—Tyler James

Introduction
Public Health interventions have failed to address the adverse health outcomes of adolescents vacillating back and forth between the criminal justice system. Research has documented that adolescent labeled as juvenile delinquents experience higher rates of illicit substance abuse, mental health issues, and higher rates of violent death than non-delinquent adolescents do(1-4). The philosophy behind these efforts suggests that reducing delinquency will improve the health outcomes among at risk adolescents. This paper will focus on the Lifer’s Juvenile Awareness Project captured in documentary “Scared Straight”, a prison-aversion program presented itself during the seventies as a possible method from deterring adolescents from criminal behavior and risky health behaviors. There have been mixed reports about the success of the Scared Straight program, this intervention represents a public health failure.

The Birth of Scared Straight
In 1978, Arnold Shapiro directed a documentary examining the “Lifer’s Juvenile Awareness Project,” implemented at the Rahway State Prison in New Jersey. The “Lifers Juvenile Awareness Program,” was offered as an alternative choice for adolescents who faced prison time for their involvement in criminal activity. The goal of this intervention was to give youth an experience of what life would be like in the prison system. The outcome that this intervention was hoping to achieve was to reduce adolescent’s risk of committing criminal or risky behaviors. The “Lifers Juvenile Awareness Program,” used real prisoners or Lifers to implement the intervention to adolescents. Lifers would “keep it real” and used excessive graphic language, violent images of men and women assaulted in prison, and role-playing to illustrate how engaging in delinquent behaviors ultimately leads to undesirable consequences, mainly landing in prison and suffering through its daily hardships.

Shapiro titled the documentary Scared Straight, and it aired nationally in 1979. In the finale of Scared Straight, Shapiro claimed that there was an 80% deterrent effectiveness among all participating adolescents and that there was 100% deterrent rate among the intervention participants during the filming of the documentary. With the lifer’s graphically demonstrating how their negative behaviors led to their imprisonment and the hardships they face inside of prison, rational thought suggests the intervention would discourage juvenile delinquents from continuing their destructive behaviors (5). This national exposure gave credibility to its effectiveness and it inspired 38 states to adopt prison-aversion programs modeled after the “Lifer’s Juvenile Awareness Project”, which due to the popularity of the documentary the public colloquially referred to as Scared Straight (6). State’s implementation of the program was very similar to the aggressiveness and intimidation tactics employed by the prisoners of the original documentary. Also, states used various criteria to determine eligibility for the intervention. Some juveniles participating in the intervention are first time offenders while others committed several criminal offenses.

Substance Use and Scared Straight
Scared Straight encompasses several of the Health Belief Model constructs used to inspire behavioral change in an individual. The behavioral outcome the intervention seeks to achieve is eliminating recidivism and encouraging adolescents to adopt more socially acceptable behaviors. According to the program, juvenile delinquents should have a high-perceived susceptibility since their behaviors led to their interaction with the criminal justice system. However, juvenile delinquents experience a high likelihood of illicit substance use and have difficulty making and maintaining a rational decision such as avoiding crime or remaining sober without assistance (1). Therefore, the co-occurrence of other issues among juvenile delinquents makes the rational thought process difficult to follow.

The glaring issue that makes this intervention a public health failure is that the intervention fails to recognize the importance of the co-occurrence of other issues among juvenile delinquents. Scared Straight fails to address the negative health outcomes such as illicit substance abuse or mental health needs of juvenile delinquents that cause them encounter the criminal justice system. Research has shown that recidivism coincides with more serious drug use—moving from marijuana to cocaine for instance (1). Studies have also shown that imprisonment negatively affects the health of individuals, particularly mental health (7-8). Solely relying on Scared Straight to address the co-occurrence of issues among juvenile delinquents represents a public health failure and evidence that treatment services need to be involved in reducing recidivism rates.

Scared Straight Fails to Provide an Effective Skills Set
Scared Straight consist of hours of Lifers talking to adolescents in an aggressive manner and use the role-playing exercises of the intervention to humiliate juvenile delinquents rather than help them learn how to perform more socially acceptable behaviors. The Scared Straight intervention fails to provide juvenile delinquents with an appropriate skill set for effectively avoiding recidivism and other delinquent behaviors. The co-occurrence of criminal behavior and illicit substance use suggests that juvenile delinquents need a new set of skills to perform more socially acceptable behaviors in mainstream society. Failing to address these issues will not engender change among juvenile delinquents because they lack the tools/resources to do so. Research supports the use cognitive-behavior therapy to change behavior successfully. Cognitive-behavioral treatment includes problem solving, negotiation, skills training, interpersonal skills training, rational-emotive therapy, role-playing and modeling, and cognitively mediated behavior modification (9).

Scared Straight Does not involve the Community or Positive Role Models
Research has shown that interventions seeking to combat recidivism prove to be more effective when the interventions are conducted in a community setting rather than institutions such as a prison (9-10). Lifers encourage juvenile delinquents to become socially responsible members within their community, yet the intervention excludes the community environment. There is a great disconnect between the goal of the intervention and the actual environments of juvenile delinquents. Not only does the intervention fail to incorporate the community within the program, juvenile delinquents do not receive information about the resources their communities or nearby communities have to offer. This is critical since the treatment services within the public sector are not easily available (1).

Evaluation
Unlike adolescents not labeled as at-risk or delinquent, juvenile delinquents have not experienced a decrease in illicit drug use. Prison-aversion programs such as Scared Straight have been unsuccessful in their attempts to decrease recidivism rates and negative health outcomes among juvenile delinquents due to their reliance on Health Belief Model constructs. Juvenile delinquents need additional resources and therapy to address co-occurring issues in conjunction with intervention leaders illustrating the negative consequences of their behaviors. This is the reason why independent evaluation of the Scared Straight intervention suggests the program is not effective. The intervention emphasizes the consequences of criminal behavior but fails to instruct juvenile delinquents from performing such behaviors. Once juvenile delinquents encounter the criminal justice system, they are aware of the consequences of their criminal behavior. Since states implemented the program with the same criterion and with the same expected outcomes stated in the “Lifer’s Juvenile Awareness Project,” they have not achieved their desired target goals in the reduction of youth coming into prison and reduction of recidivism among those that have been in the incarceration system.

Conclusion
Despite the promoted effectiveness of Scared Straight this interventions has failed to reduce recidivism effectively among juvenile delinquents. The structure of Scared Straight lacks the critical elements identified by research on efficacious methods of reducing recidivism. The major flaws of the intervention are it is not continuous, it inadequately addresses co-occurring issues such as substance abuse, it fails to provide juvenile delinquents with appropriate skills set for maintaining socially responsible behaviors, and it does not involve the community environments of juvenile delinquents.

With the dearth of public treatment services, linking juvenile delinquents with positive role models is critical to assist them in becoming socially responsible members of their communities. The Lifers serve as models of behavior for juvenile delinquents not to adopt, but, since the prisoners are removed from society, they fail to serve as an effective model for adolescents to emulate when they return to their communities. Positive community role models are imperative because not only do they serve as effective models for juvenile delinquents, but they also provide long-term assistance for juvenile delinquents as well. Juvenile adolescents need to interact with mentors who have reformed their criminal behaviors or maintained sobriety, and now behave as socially responsible individuals.

Since the program does not employ these crucial components, Scared Straight fails to combat recidivism and it reiterates what juvenile delinquents learned upon their first encounter with the criminal justice system; that is, their delinquent behaviors will result in negative consequences. Without this intervention teaching juvenile delinquents how they can combat recidivism and other co-occurring issues, Scared Straight will remain a public health failure.

References
1. Dembo R, Williams L, Schmeidler J, Drug Abuse among Juvenile Detainees Annals of American Academy of Political and Social Science 1992; 521: 28-41
2. Lennings CJ, Copeland J and Howard J Substance Use Patterns of Young Offenders and Violent Crime Aggressive Behavior 2003; 29:414-422
3. Teplin L, * McClelland GM, Abram KM, and Mileusnic D, Early Violent Death Among Delinquent Youth: A Prospective Longitudinal Study Pediatrics 2005; 115: 586-1593
4. Wiesner, M; Michael Windle Young Adult Substance Use and Depression as a Consequence of Delinquency Trajectories During Middle Adolescence Journal of Research on Adolescence 2006; 16:239-254
5. Petrosino, A; Carolyn Turpin-Petrosino, James O. Finckenauer Well-Meaning Programs Have Harmful Effects! Lessons From Experiments of Programs Such as Scared Straight Crime & Delinquency 2000; 46: 354-379
6. Buckner JC, Chesney-Lind M Dramatic Cures For Juvenile Crime An Evaluation of a Prisoner Run Delinquency Prevention Program Criminal Justice and Behavior 1983;10:227-247
7. Freedenthal, S., M.Vaughn, J. Jenson, and M. Howard Inhalant Use and Suicidality Among Incarcerated Youth Drug Alcohol Depend. 2007; 90:81-88
8. Teplin La, McClelland GM, Dulcan MK, Mericle AA Psychiatric disorders in youth in Juvenile Detention Arch Gen Psychiatry 2002; 59: 1133-1143
9. Pearson F, Lipton D, Cleland C, Yee D The Effects of Behavioral/Cognitive-Behavioral Programs on Recidivism Crime & Delinquency 2002; 48:476-496
10. Greenwood P, Zimring F One More Chance: The pursuit of Promising Interventions Strategies for Chronic Juvenile Offenders Santa Monica, CA:RAND, 1985)

Wrong Agenda: Early Detection Program’s Failure to Promote the Early Detection of Cervical Cancer Among at Risk Women in Florida–Emily Butler

Introduction
Cervical cancer was once a leading cause of cancer death for women in the United States. The availability of the Papanicolaou smear (Pap test) as an early detection tool is largely credited for reducing the mortality rate by 74% between the years 1955 and 1992 (1). Despite the availability of early detection, it is estimated that 11,150 women will be diagnosed with cervical cancer in the United States during the year 2007. Furthermore, although cervical cancer treatments may be curative or life extending, approximately 3,670 women are expected to die of the disease during the same year. The Pap test allows cervical cancer to be detected and treated before it becomes cancerous, in its earliest most curable stage, (2). Although it does not yield perfect results, it is believed that the vast majority of cervical cancer cases can be prevented if women participate in regular screening with the Pap test. Approximately 60% to 80% of new cervical cancer diagnoses occur in women who report not having a Pap test in the last five years (3).

In an effort to improve access to screenings for breast and cervical cancer, Congress passed The Breast and Cervical Cancer Mortality Prevention Act of 1990. The Act established the Centers for Disease Control and Prevention’s National Breast and Cervical Cancer Early Detection Program (NBCCEDP) to provide early detection screenings for low income and uninsured women in all 50 states. The expressed goal of the program is to provide breast cancer screenings for women between the ages of 40 and 64 and cervical cancer screenings for women between 18 and 64 years of age, and at or below 250% of federal poverty level. The program has to date provided more than 6.9 million screenings (4).

Although a success in many respects, the NBCCEDP’s lack of funding prohibits many categorically eligible women from accessing free screenings. Nationally, funding is only available to offer screenings to four out of five women who should be eligible according to the program’s age and financial qualifications. Some states match or contribute to program funding with state funds, thereby allowing as many eligible women to participate as possible. Eleven states, however, do not contribute any state funds to their state’s screening program (5).

Without adequate funding, many states choose to limit the availability of screenings to women in select geographic areas and in particular age groups, thereby excluding at risk women from accessing free screenings. The availability of cervical cancer screenings in the state of Florida serves as a case example for the limitations of the program under budgetary constraints. Florida is one of the eleven states that does not contribute any state funds to the program (4). The Florida Breast and Cervical Cancer Early Detection Program (FBCCEDP) limits cervical cancer screenings to women between the ages of 50 and 64, narrows financial eligibility to women at or below 200% of Federal Poverty Level, and offers the program in only 16 sites in the state (6). Due to these limitations, the FBCCEDP is ineffective in screening young, low-income, and rural women who are at risk for developing cervical cancer. It is estimated that there were 842 new cases of invasive cervical cancer diagnosed in Florida in the year 2003. Florida’s incidence rate of cervical cancer in 2003, 9.2 new cases per 100,000 women, is above the national incidence rate of 8.1 and ranks 14th highest in the nation (8). Although the incidence of cervical cancer is lower than many other types of cancer, early detection efforts warrant attention as many of these cases might be prevented with increased access to and use of the Pap test.

Geographic Inaccessibility Prohibits Utilization of Screenings
Although the FBCCEDP offers services to women in all 67 Florida counties who meet program requirements, there are only 16 sites where the screening services are actually offered (6). Even if a woman qualifies for a screening, she may not have the means to travel to a program site to have the screening done. Eligible women, between the ages of 50 and 65, are of working age and may find it difficult to take time off work to travel to a site. Furthermore, eligible women with incomes less than 200% of Federal Poverty level may not have transportation or the means to afford the expense of travel. The geographic distribution of screening sites may effectively prohibit eligible women from traveling to access a site that offers screenings. It is also highly possible that these women in more rural or remote areas may be less able to afford a Pap test from an alternate provider, if there is even a provider available within the local community. Women living in rural counties, especially in counties not adjacent to a county with an urban area, are less likely to have health insurance coverage or have access to employer-sponsored health insurance (9). Compared to the urban population, people in rural areas also earn lower incomes and are less healthy in general (9.)

Age Criteria Creates a Public Agenda
Under the FBCCEDP program, women under the age of 50 are not eligible to receive screenings despite financial eligibility (6). Although it is rare for a woman under the age of 20 to develop cervical cancer, it is estimated that 50% of cases occur in women between age 35 and 55 (2). Therefore, a significant number of at risk women are not eligible for program services. By systematically excluding younger women, the program may be inadvertently setting a public agenda to promote screening-seeking behavior primarily in older women. A public program’s emphasis on a particular public health issue may direct the public’s attention to perceive the issue as being “high on the agenda” (7). In this case, the availability of a public program to offer cervical cancer screenings for women only between the ages of 50 and 64 may inadvertently set the public’s agenda to view cervical cancer as a risk primarily in this age group. It is then possible that younger, excluded women might not seek screenings from other providers because they do not perceive that their risk as “high on the agenda,” or of significant proportion. Although likely unintended, the program’s age restrictions may be creating a public perception that younger women are not as at risk of developing cervical cancer, when in fact they represent a significant proportion of new cases.

Lack of an Alternative Screening Option
The NBCCEDP and the FBCCEDP do not offer an alternate screening option for the approximate 80% of women that should, but do not qualify for screening services. Women that cannot access screenings are left to navigate the patchwork system of charitable medical services offered by other organizations and institutions. If the program offered a solution, such as a sliding scale fee for excluded women, more women might access reduced cost services even though they could not qualify for a free screening. Without a viable alternative, many women may choose to forgo screenings altogether.

According to the theory of Diffusion of Innovations, health behaviors may be increasingly adopted over time as more people begin to perform the behavior (7). By neglecting to offer a low cost or alternate screening option for ineligible women, the FBCCEDP fails to utilize the potential benefits of this theory. If more women were able to access screenings, perhaps at a small personal cost, adoption of the behavior might increase more rapidly.

Conclusion
The FBCCEDP fails to offer cervical cancer screenings to a large population of at risk women in the state of Florida. Although funding may be limited, careful attention should be paid to the way that screenings are made available so that the most at risk women have the opportunity to stop cervical cancer at its earliest stage. The systematic disqualification of younger women and women in rural areas may prevent some of these at risk women from accessing a Pap test altogether. Furthermore, this inaccessibility may consequently portray a message that younger women are not as at risk of developing cervical cancer. The program does not seize the opportunity to encourage an early habit of annual Pap test screening. The FBCCEDP should be revised to more equitably distribute screening services and encourage more women to access cervical cancer screenings.

Compared to other cancer screening tools, the Pap test is a relatively inexpensive intervention. Although cervical cancer incidence rates have declined rapidly since its innovation, there is no reason why rates should not continue to fall. With appropriately designed public health interventions, the Pap test could be made available to more at risk women.

REFERENCES
1. National Cancer Institute. Cancer Advances in Focus: Cervical Cancer. National Cancer Institute: 2006. Accessed 8 December 2007, from
http://www.cancer.gov/aboutnci/cancer-advances-in-focus/cervical
2. American Cancer Society. Detailed Guide: Cervical Cancer. Atlanta, GA: American Cancer Society: 2007. Accessed 8 December 2007, from http://www.cancer.org/docroot/CRI/CRI_2_3x.asp?rnav=cridg&dt=8
3. American Cancer Society. Cancer Facts & Figures. Atlanta, GA: American Cancer Society: 2007.
4. Centers for Disease Control and Prevention. National Breast and Cervical Cancer Early Detection Program. Atlanta, GA: Centers for Disease Control and Prevention: 2007. Accessed 8 December 2007, from http://www.cdc.gov/cancer/nbccedp/about.htm
5. The American Cancer Society Cancer Action Network. How Do You Measure Up?: A Progress Report on State Legislative Activity to Reduce Cancer Incidence and Mortality, August 2007. Washington, DC: ACS CAN: 2007.
6. Florida Department of Health. Program Overview: the Florida Breast and Cervical Cancer Early Detection Program. State of Florida: 2007. Accessed 8 December 2007, from http://www.doh.state.fl.us/Family/bcc/default.html
7. Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
8. State Cancer Profiles. Incidence Rate Report by State. National Cancer Institute: 2007. Accessed 8 December 2007, from http://statecancerprofiles.cancer.gov/incidencerates/index.php?stateFIPS=00&cancer=057&race=00&age=001&type=incd&sortVariableName=rate&sortOrder=desc
9. Kaiser Commission on Medicaid and the Uninsured. The Uninsured in Rural America: Key Facts. The Henry J. Kaiser Family Foundation. April 2003.

The Strategy Behind Florida’s “Truth” Campaign: An Infirm Public Health Intervention—Meng-Yun Lin

Introduction
Smoking has been a public health concern afflicting national and international communities. In 2000, worldwide there were about 5 million deaths related to smoking, in particular between 1997-2001 there were over 435000 deaths attributable to cigarette use ([1]). Centers for Disease Control and Prevention (CDC) conducted a survey in 2006 and reported that 20.8% adults and 23.9% young adults, younger than 18 years old, are current smokers. This survey surprisingly showed that younger kids reported to be current smokers. In the same report, adults reported that they were daily smokers (71%) and smoked their first cigarette before the age of 18 years old (90%) ([2]); 60% started before age 14([3]). Researchers studying senior high school students reported that in 2001, 19% of them reported daily smoking. Studies indicate that people who start to smoke at a younger age are at higher risk for cancer, heart disease, stroke and chronic obstructive lung disease ([4]). No doubt, tobacco use is a serious public health issue as dependence begins during childhood or adolescence in the majority of tobacco users. Public health interventions should target young kids who are at risk to start smoking, to prevent and reduce the long term consequences of tobacco exposure.


"Truth" campaign: a counter-marketing, anti-tobacco media program
In 1997, the Tobacco Industry and the state of Florida reached a settlement of 11.3 billion dollars and 200 million dollars per year to reduce smoking among kids. ([5],[6]). The program made it possible to markedly expand tobacco control programs in the states and provided for the creation of a new foundation, American Legacy Foundation, whose primary purpose is to combat tobacco use in the United States. Florida hired Crispin Porter & Bogusky as their advertising agency to take the lead on the Florida’s youth anti-tobacco project. The agency was charged with creating a series of social marketing interventions incorporating mass media advertisement and web based education sites. This campaign was eventually called the “Truth campaign.” In 1998, a study indicated the percentage of youth tobacco users declined by 7.4 percentage points in middle school and 4.8 percentage points in high school. The "truth" campaign has been well received by public and reduced smoker among youths. The only negative reaction to the campaign has been, predictably, from the tobacco industry ([7]).


It seems that the “Truth campaign” is much successful in youth smoker control, however, considering the context of behavior theories it is an inform public health intervention. In this paper, first, I will look at the modified social marketing theory that the “Truth” campaign uses and focus on the flaws of the anti-tobacco campaign. In my view, the unconventional youth marketing theory is flawed because it neglects to consider the individual factors and environmental effect, rather than just looking at the group level factors. Second, behavior is part of a continuous interactive cycle that includes individuals and their physical and culture environment. I will contemplate the program based on social cognitive theory (SCT) (9-15). Final, I will also argue that the Florida’s “Truth Campaign” should be a model across the nation to decrease smoking among kids ([8]) and discuss how media tobacco control programs use Social Marketing Theory ([9],[10]).


"Truth" campaign lacks tools to promote self- efficacy
Florida’s “truth” campaign is not valid because it does not take into account individual factors for example self-efficacy, self-control and behavioral capability. According to the SCT ([11],[12],[13],[14]), changing behavior includes the following: individual characteristics, environmental factors and reciprocal determinism. Especially, individual factors similar to an internal engine switch and further activate the behavior of quitting smoking or keeping from smoking. For example, self-efficacy as the representative of confidence decides whether kids can shift their behavior to healthier one. And behavior capability meaning the knowledge or skill related to change behavior determines if one can accomplish changing process. Here, I generalize the above-mentioned elements as self-efficacy, teenagers’ ability of devoting themselves to changing behavior. Only when teenagers possess internal impetus can they possibly achieve the action of changing behavior. However, youths at the stage of developing personality usually have lower willpower and lack of self-efficacy. Therefore, it is more difficult for teenagers to make up their mind of changing behavior and to maintain changed behavior.


SCT is based on self-efficacy, and assumes that people have the belief that they could perform a behavior. In the anti-tobacco campaign, even though the ads are very impressive and successfully attract teenagers’ attention, self-efficacy can not be given to students through the ad campaign, therefore reducing their ability to make behavioral changes. In other words advertising succeeds in awaking kids to the “truth”, the death toll of smoking, it does not result in devoting to quit smoking or keeping from cigarette. After all, knowing is one thing and doing is another thing. Elisia L. Cohen ., 2007, conducted a study looking at televised anti-smoking ads to discourage adult and teenagers from smoking, and this study reported that the ads focused on people’s attitudes on smoking([15]). The study also reported that the ads mentioned the benefits of not smoking 61% of the time, while barriers to smoking were mentions 17% of the time. This advertisement campaign demonstrates how anti-smoking campaigns emphasize on the consequences of smoking more that the concept of self-efficacy.


The SCT also states that people need three things to maintain self-efficacy: expectations and expectancies, self-control and emotional coping ability. The people’s expectation about what will happen after changed behavior and if the expect outcome is rewarded. The level of strong will in terms of making the change. Their ability to deal with the emotions involved in the behavior change. To completely change behavior, maintaining self-efficacy plays a crucial role in sustaining changed behavior (11, 12). Campaigns like the “Truth” campaign may get teenagers attention; however teenagers with lower self-esteem may have a more difficult time to change smoking behaviors. And teenagers with low self esteem may have inadequate behavioral and emotional skills to quiet smoking and give up the wayside while suffering from emotional strikes involved in changing step. Finally youth’s behaviors often shift between positive and negative behaviors, making television ads anti-smoking campaigns ineffective.


"Truth" campaign does not emphasize environment factors
This program is ineffective because it regards the young tobacco users as a relatively independent group and ignores the external content in that teenagers live in. Social Cognitive Theory also tells us that individuals social and physical environmental factors play an important role to change behavior. For example, the behavior of other people and the consequences of that behavior cause vicarious learning. Different circumstances in which the anti-smoking communicate may make viewers product distinct perceptions concerning tobacco. In addition, negative or positive reinforcements among live environment give teens various responses to cigarette (9-15). In the program targeted on young people, gender, geography and family’s tobacco use are all critical factors implicating in the intervention outcome. On the other hand, I think temperate education or persuasion is insufficient to reduce youth tobacco prevalence and hence a rigid legislation may be a more active and dominated kind of intervention.
Teenagers that have parents and other family members that smoke are more likely to have access to cigarettes and are at high risk to start smoking at a young age. In a study that compared teenagers with parents that smoked with teenagers that didn’t have parents that smoked reported that the Truth campaign was more effective in preventing smoking among youths that didn’t have parents who smoked ([16]). In other words, in a tobacco-using environment, kids are more likely to access cigarette and it is harder to keep them from smoking. It is clear that access to cigarettes in a home environment and parents that smoke are role models that offset the goal of the Truth campaign. Anti-smoking campaigns should not only target teenagers’ peers, but also include family, because they can also have a strong influence on their smoking behaviors.


Policy changes are an effective way to effect the way that Anti-tobacco campaigns are focused on education or persuasion interventions ([17],[18],[19],[20]). At first, with high public visibility and strong public support, “truth” campaign is somehow significantly successful. Many short-term surveys indicated the teen smoking prevalence rate dropped from 23.3% to 20.9%. Nevertheless, in 1999, the state legislature cut the program’s funding from $70.5 million to $38.7 million, and the Bush administration dismantled the program’s administrative structure ([21]). These changes effected the implementation of the “Truth” campaign, as not only limited the funding support but also weakened the political support for this campaign. Public Health interventions would be more stable if intervention programs were pushed through legislation and became enacted bills. This would allow interventions to become established to be more effective to change behavior. Because smoking prevalence is preventable through precluding potential smoker, legislating will be a powerful intervention. Lack of legislation to control tobacco use resulted in dramatic rise in tobacco consumption in India, the third largest grower of tobacco in the world ([22]). It is more economical to prevent a problem in advance rather then to deal with the puzzle while it developed.


"Truth" campaign risks overestimated the efficacy of marketing
The Truth campaign is too optimistic in having a social marketing media campaign address teenagers issues to effectively change their smoking behavior. In this campaign, social marketing theory sees behavior change a selling product to teenagers. Every year, new public health mass media campaigns are launched attempting to change health behavior and improve health outcomes. Recent years, these campaigns enter a crowded media environment filled with messages from competing limited sources ([23]). With limited government funding, state funded agencies and organizations also have limited resources and political support from legislators to help with funding resources.


Due to the widespread communication, “truth campaign” produced a substantial impact reducing cigarette consumption and stimulating the development of policies to eliminate environmental tobacco exposure. Research looking at teenagers smoking attitudes report that they perceive the serious consequences of smoking from anti-tobacco ads regardless of their sex and ethnicity ([24]). However, such achievements do not therefore lead to the reduction of smoking initiation and smoker population among adolescents in a long term frame. As I mentioned before, if there were state legislation supporting anti-tobacco campaigns it would give them the stability to have long term impacts on the reduction of teenagers smoking rates ([25],[26]) .


The past studies designed to estimate the outcome of “truth” campaign revealed controversial results: some reports showed ads had created a great decrease in teen smoking ([27]) as other studies claimed there were no apparent effect ([28]). The differences in measurement of public health media program might contribute to the effect of differences observed. However, even existing positive outcome the conclusions regarding effectiveness is limited and exclusive. For instance, adolescents who live in tobacco producing regions appear to be less responsive to anti-industry ads than their counterparts in non-tobacco producing regions ([29]). Also, although the anti-smoking campaign had an effect on both sexes, less of an effect was required to influence young women than young men and the effect of ads on young men continued to be weakened ([30]). In addition, study found industry sponsored anti-smoking ads do more to promote corporate image than to prevent youth smoking ([31]). Between traditional marketing-brand cigarette ads, the counter- conventional anti-smoking campaign marketing public health issue seems not as helpful for youth as we expecting.


Conclusion
The Florida’s “truth” campaign uses a variety of scenarios to address the death toll caused by cigarette using, during 1998. The campaign ads use fear and humors tactics to attract teenagers’ attention ([32]), however anti-smoking TV media campaigns are unlikely to be effective, and could have negative unintended consequences. It is crucial to prevention of risk behavior before it becomes embedded in an individual's life ([33]), therefore recent anti-smoking programs principally targeted on young adults. A public health intervention such as the true campaign simple through advertising its idea of anti-smoking, however, is not sufficient. First, anti-Smoking ad campaigns should further focus on the complexity of the behavior the intervention is trying to change. These include individual and social factors. Intervention should not only targets on teenagers but consider them with their parents, families, and communities as a whole. Second, we should reduce the chance of letting kids expose to a smoking-use environment. Forbid smoking around children in daily life as ban against smoking in public places such as schools and hospitals. Increase cigarette taxes according to the growing tobacco consumption and strictly forbid young adults purchasing cigarette through legislating. Third, give adolescents the ability of choosing healthier behavior by establishing their self-efficacy. Set physician counseling to introduce smoking cessation and help children quit smoking. As many teenagers regard smoking as an emblem of independence like adults , through public education teach them anti-smoking is even a mature and cool behavior and giving up smoking is as easy as engaging in. The more extensively a behavior is embedded, the more difficult it is to alter such behavior. Relative levels of embeddedness of the risk behavior and its entanglement with other nonrisky behavior evolve and change throughout one's life course. Without controlling the trend of young smoking population, it would reverse the decline in whole smoking prevalence seen in the past several decades.


REFERENCES
[1] Centers for Disease Control and Prevention. Annual Deaths Attributable to Cigarette Smoking—United States, 1997–2001. http://www.cdc.gov/tobacco/data_statistics/tables/health/attrdths.htm
[2] US Department of Health and Human Services. Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention, National Center to Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1994
[3] Epps RP, Manley MW. A physician’s guide to preventing tobacco use during childhood and adolescence. Pediatrics 1991; 88:140–144.
[4] Davis JW, Shelton L, Watanabe IS, Arnold J. Passive smoking affects endothelium and platelets. Arch Intern Med 1989; 149:386–389.
[5] Jeffrey Hicks. The strategy behind Florida’s “truth” campaign. Tobacco Control 2001; 10:3-5.
[6] Bauer UE, Johoson TM, Hopkins RS, et al. Changes in youth cigarette use and intentions following implementation of a tobacco control program. JAMA 2000; 284:723-728.
[7] C Healton. Who's afraid of the truth? American Journal of Public Health 2001; 91:554-558.
[8] Zucker D, Hopkins RS, Sly DF, Urich J, Kershaw JM, Solari S. Florida's "truth" campaign: a counter-marketing, anti-tobacco media campaign. J Public Health Manag Pract. 2000;6(3):1-6.
[9] Philip Kotler, Gerald Zaltman. Social Marketing: An Approach to Planned Social Change. Journal of Marketing 1971; 35(3): 3-12.
[10] Lefebvre, R. Craig; Flora, June A. Social Marketing and Public Health Intervention. Health Education Quarterly 1988;15(3): 299-315.
[11] Mark Edberg. Social, Culture, and Environmental Theories (PartI) (pp 51-64). In: Mark Edberg, ed. Essentials of Health Behavior. Sudbury, MA: Junes and Bartlett, 2007.
[12] Bandura, A. Social cognitive theory. Annals of child development 1989; 6:1-60.
[13] Bandura, A. Social cognitive theory of self-regulation. Organizational behavior and human decision processes 1991; 50:248-287.
[14] Bandura, A. Human agency in social cognitive theory. American Psychologist 1981; 44:1175-1184.
[15] Elisia L. Cohen . Original: Anti-Smoking Media Campaign Messages: Theory and Practice. Health Communication 2007; 22(2), 91-102.
[16] David F. Sly, Richard S. Hopkins, Edward Trapido, ScD, Sarah Ray. Influence of a Counteradvertising Media Campaign on Initiation of Smoking: The Florida “truth” Campaign. American Journal of Public Health 2001; 91(2): 233-238.
[17] Chin R. Benne KD. General strategies for effective change in human systems. In Bennis W et al. (eds.): The planning of Change (3rd edition), pp. 22-45. New York: Holt, Rinehart and Winston, 1976
[18] Rosenblatt M. should our judicial system and legislatures protect infants and children from second-hand tobacco smoke? Children’s Legal Right Journal 2005; 25:37-50
[19] Siegel M. Education and persuasion versus coercion as public health approaches. The Rest of the Story: Tobacco News Analysis and Commentary (blog). May 4, 2006.
[20] Siegel M. Making it unlawful to smoke around children could have detrimental effect on children’s health, especially among disadvantaged populations. The Rest of the Story: Tobacco News Analysis and Commentary (blog). May 22, 2006.
[21] Michael S. Givel, Stanton A. Glantz. Failure to Defend a Successful State Tobacco Control Program: Policy Lessons From Florida American. Journal of Public Health 2000; 90(5): 762-767.
[22] Riti Shimkhada, John W. Peabody. Tobacco control in India. Bull World Health Organ 2003; 81(1): 48-52.
[23] Whitney Randolph, K. Viswanath. Lessons Learned from Public Health Mass Media Campaigns: Marketing Health in a Crowded Media World. Annual Review of Public Health 2004; 25: 419-437.
[24] L Biener. Anti-tobacco advertisements by Massachusetts and Philip Morris: what teenagers think. Tobacco Control 2002; 11:43-46.
[25] Michael Siegel & Lois Biener. Evaluating the Impact of Statewide Anti-Tobacco Campaigns: The Massachusetts and California Tobacco Control Programs. Journal of Social Issues 1997; 53(1):147-168.
[26] Michael Siegel. THE EFFECTIVENESS OF STATE-LEVEL TOBACCO CONTROL INTERVENTIONS: A Review of Program Implementation and Behavioral Outcomes. Annual Review of Public Health 2002; 23: 45-71.
[27] Matthew C. Farrelly, Kevin C. Davis, M. Lyndon Haviland, Peter Messeri, and Cheryl G. Healton. Evidence of a Dose–Response Relationship Between “truth”Anti-smoking Ads and Youth Smoking Prevalence. American Journal of Public Health 2005; 95(3): 425-431.
[28] Matthew C. Farrelly, Cheryl G. Healton, Kevin C. Davis, Peter Messeri, James C. Hersey, and M. Lyndon Haviland. Getting to the Truth: Evaluating National Tobacco Countermarketing Campaigns. American Journal of Public Health 2002; 92(6):901-907.
[29] J F Thrasher, J Niederdeppe, M C Farrelly, K C Davis, K M Ribisl and M L Haviland. The impact of anti-tobacco industry prevention messages in tobacco producing regions: evidence from the US truth® campaign. Tobacco Control 2004;13:283-288
[30] David F. Sly, Richard S. Hopkins, Edward Trapido and Sarah Ray. Influence of a Counteradvertising Media Campaign on Initiation of Smoking: The Florida “truth” Campaign. American Journal of Public Health 2001; 91(2): 233-238.
[31] L Henriksen, A L Dauphinee, Y Wang and S P Fortmann. Industry sponsored anti-smoking ads and adolescent reactance: test of a boomerang effect. Tobacco Control 2006; 15:13-18.
[32] Cheryl Healton. Who’s Afraid of the Truth? American Journal of Public Health 2001; 91(4): 554-558.
[33] Melanie Booth-Butterfield . Embedded Health Behaviors From Adolescence to Adulthood: The Impact of Tobacco. Health Communication 2003; 15(2):171-184.

MRSA Infections:A Deadly But Preventable Disease-Kelly Donnelly

Methicillin-resistant Staphylococcus aureus (MRSA) infections have emerged in patients who do not have established risk factors and currently our systems are not doing enough to prevent the increasing risks of our citizens. In the United States, Staphyloccus aureus is the most common cause of skin and soft-tissue infections, as well as of invasive infections acquired in hospitals (1). According to CDC data, the proportion of infections that are antimicrobial resistant has been on the rise (2). In 1974, MRSA infections accounted for two percent of the total number of staph infections; in 1995 it was 22%; in 2004 it was 63%. Over the past 20 years, these infections have been limited to patients in hospitals or long-term care facilities but a more infectious strain is causing grave illnesses and deaths in our healthy communities.

MRSA is a strain of a super bug that has been found in non-hospitalized patients and is becoming a common and serious problem. These infections usually involving the skin or soft tissues are normally found on the skin or nose in about one third of the population. If you have staph on your skin or in your nose but aren’t sick, you are said to be colonized but not infected with MRSA. Healthy people can be colonized with MRSA and have no ill effects, however, they can pass the germ to others (3). The good news is it is still treatable with drugs. But as this super bug becomes more infectious and resistant to more antibiotics it poses a considerable public health risk. Failures in our communities at the Local, City and State levels are equally responsible for this deadly super bug resistance and its continued spread. Locally, our doctors are over prescribing antibiotics, the cities hospitals have inadequate infection control procedures and our state continues to have overcrowded living conditions.

MRSA is considered to be a superbug infection, that has evolved from a variety of sources one that includes decades of excessive and unnecessary antibiotic use. Since their inception in the 1940’s antibiotics have been over used. Although prescription antibiotics are the main culprit they are not the only one. In the US, antibiotics are in everything from our food to our water system. Exposure to antibiotics is unique to the US because other countries have stricter regulations on antibiotic use. Unlike the US, other countries forbid antibiotic use in animals so that these types of resistant bacteria are not easily formed. The increased frequency of antibiotics should be of great concern to medical providers and the public. Since the development of these novel antibiotics their use has been for everything including the common cold or flu but as we now know most of these aliments are unaffected by antibiotics and eventually resolve on their own.

To keep antibiotic resistance under control, reduced levels of antibiotic prescribing must be more consistent. Antibiotics should be used only when medically necessary and not for everyday medical problems. Doctors also need to encourage patients to finish their whole course of antibiotics regardless of whether or not they feel better. When patients finish their medication as instructed by their doctor they decrease the chance of infections returning. Continuity of patient care should also continue even after the patient leaves the doctors office with continued follow up with the patient.

There are individual and social factors that can help reduce the number of these infections. One solution would be for doctors to refrain from prescribing antibiotics for common viruses. Another recommendation would be for doctors to call patients a few days after treatment to assess the resolution of illness while giving patients an opportunity to clarify any new or unresolved issues about their treatment or medication.

Infection control measures need to be improved in hospitals too. Why is it that these infections are now being reported in healthy non-hospitalized persons who have not been in direct contact with a healthcare provider or colonized patients? Once thought of as a “hospital acquired infection” it is now spreading in epidemic proportions to otherwise healthy individuals. In addition, MRSA infections are common in patients who have indwelling vascular catheters for dialysis or other medical treatments. However during the past decade, multiple reports of these infections have been reported in patients who lack the above risk factors (4). This raises some serious concern about the transmission of MRSA outside of the healthcare system.

Infection control protocols and procedures within the doctor’s office, clinics and hospitals are vital in preventing the compromised and non compromised patients from acquiring this disease. Doctors’ offices and clinics are understaffed and overbooked with patients causing staff to focus attention on seeing more patients which allows less time between patients to disinfect or properly wash hands in between patients. Having worked in these types of settings for many years, I personally have observed staff only washing their hands less than half the time they should. I have even observed staff not changing gloves between patients as they should. Hand-washing is the most simplistic and preventable way of spreading germs, yet it is improperly done by the most people as well as medical staff.

Person to person contact is the leading spread of this disease. To help prevent spread of this super bug hospitals should require staff and visitors to wear gloves and gowns while visiting patients if the cause of their sickness is unknown. Clinicians also need to take part in the emergence of this super bug and stop its spread throughout the community. Clinicians need to be educated in using the appropriate antibiotic therapy and know when to initiate it as soon as infection with this pathogen is suspected (5).

Over crowded living conditions is a major breeding ground for this communicable disease. Homeless shelters and people forced to live in community homes continue to struggle to have adequate housing with more people and less housing. Due to the lack of resources and low economic status of these families they are forced to share personal belongings, blankets, and clothes. By sharing these items it puts these people at higher risk of acquiring this disease. Communities with people living under these stressful housing situations are also less likely to have access to good medical resources. These same families don’t have or can’t afford medical care for treatment of sickness and not to mention preventative care. So what may appear to be a spider bite to a person in this crowded community may indeed be a sign of a MRSA infection but it may go unnoticed and untreated.

Institutions such as prisons, schools, and colleges are other community locations that are at high risk for getting MRSA infections. Prisons are exceptionally susceptible to communicable disease just by the mere fact that inmates are living in extremely close quarters of one other. The risk of promiscuous, unprotected sex, same sex is high in prison. Prisoners may have open sores and cuts but receive less medical attention or intervention. This disease presents as a mild skin infection but can develop into something more serious such as sepsis or organ failure without proper diagnosis and treatment. In college, students are at especially high risk. Students in school may be apt to share things like towels and razors both of which can potentially carry this germ.

If college students are involved in sports especially contact sports they are at especially high risk. Since MRSA is so contagious anything such as sharing towels or sports equipment could expose you to this germ. Football, basketball and wrestling have the highest incidence of MRSA because of the physical contact, and the most prominent areas of infection include the lower leg, forearm and knee (6).

Those with HIV or auto immune diseases are at especially high risk due to their weakened immune systems. These days it’s imperative that you be your own health advocate and help assist in advocating for those that are sick and young in our community. Schools too need to do more to protect our children and to educate their parents on MRSA infection and its spread. One solution may be for information to be sent home on a more regular basis about the spread of disease and not just when a crisis strikes-- because by then it’s too late. All information should be disseminated in a variety of ways and in those languages appropriate to the community.
Prevention methods need to be taught and enforced and accountability needs to be given to all facilities including: schools, hospitals, rehabilitation centers and elderly facilities. But currently there are no mandatory reporting procedures in schools, and according to the CDC; the decision to make a particular disease reportable to public health authorities is made on the state level based on the needs of that state.

Information is power--so its time to contact your local and state political offices with phone calls and letters demanding that this contagious communicable disease be reported because this disease is not prejudice and it has no racial or socioeconomic boundaries, it affects all. The public needs to be informed and educated about MRSA and its potential spread. Massive public education campaigns need to be able to educate and inform those with and without computers and be multi-lingual and in all public places. Hospital protocols and procedures should be strictly followed in all hospitals and by all staff and accountability taken when they are not. Continued education and in-services on proper hand washing techniques are necessary for all staff on a regular basis or as staff change and turn over.

Schools need to educate staff and students on prevention and susceptibility of this disease. Because this disease is more commonly spread by hands through person to person contact with an infected person it can also be transmitted by towels, clothes and other objects. Schools should make it mandatory and forbid sharing of personal items. School personnel and coaches need to constantly remind athletes and parents to make sure all equipment and clothes are washed thoroughly after each use. But good hygiene is one of the most fundamental ways to avoid its spread. Showers should also be mandatory before and after physical sports or contact games and locker rooms should disinfected daily. All staff need to take part in disease prevention.
Well-designed, community based studies with adequate risk factor analysis are required to further elucidate the epidemiology of CA-MRSA and to improve strategies to control MRSA in both the community and hospital settings (6).

The spread of MRSA is preventable. Despite marked efforts, prevention, spread and patient safety have not improved. There is simply not enough being done to prevent the spread of MRSA and not nearly enough being done to educate the public on its prevention. Targeted educational interventions are needed to increase awareness and improve prevention and management of these infections. Our local hospitals, city community services and state representatives have failed us here. MRSA is only one really important reason why public health officials need to persuade the public to share the responsibility for infection control and adopt better standards of day-to-day hygiene. To achieve this shared responsibility, however, we need to abandon our fragmented approach to hygiene promotion and adopt a concerted approach that looks at hygiene from the point of view of the family and the range of problems that they face in protecting themselves from infection (8). If we had more forward-thinking by our authorities this too could be another avenue where we could curb the continued resistance of this super bug.

REFERENCES
1. National Center for Infectious Disease. Methicillin-resistant Staphyloccus
aureus (MRSA), 2003. http://www.cdc.gov/ncidod/aip/research/mrsa.html

2. Department of Health and Human Services. Centers for Disease Control and
Prevention. MRSA in Healthcare Settings, 2007. http://www.cdc.gov/ncidod/dhqp/ar_MRSA_spotlight_2006.html

3. Mayo Clinic. Infectious Disease. MRSA Infection.
http://www.mayoclinic.com/health/mrsa/DS00735

4. Emerging Infectious Disease 13.8 (August 2007): p 1195 (6)

5.Curr Opin Infect Dis. 2006 Apr; 10 (2): 161-8 Pub Med. http://www.ncbi.nlm.nih.gov/sites/entrez?

6. IDEA Fitness Journal 4.8 (Sept 2007): p 17 (1).

7. Clin Microbiol Infect. 2006 Mar;12 Suppl 1:9-15. PubMed.
http://www.ncbi.nlm.nih.gov/sites/entrez?

8. Gould IM. CAMRSA: can we control it? Lancet 2006; 368: 824-26

BMI Report Cards: Bafflingly Misguided and Irresponsible – Alicia Fraser

Introduction
The public health community has declared an obesity epidemic, both in the United States and abroad (1, 2). Between 1980 and 2000, the prevalence of obesity in the US more than doubled, rising from 15% to 31% of the population (3). In children, the prevalence tripled during that same 20-year period (4). Similar trends have occurred across the world (2) prompting the World Health Organization (WHO) to convene a consultation on obesity to “review current epidemiological information, contributing factors and associated consequences” (5). The WHO review identified a number of adverse health outcomes associated with obesity including coronary heart disease, hypertension, stroke, certain types of cancer, osteoarthritis, sleep apnea, and type 2 diabetes (5).

As the results of the WHO review confirm, the sudden rise in obesity prevalence is certainly cause for concern. Accordingly, there has been a surge of obesity research as well as treatment and prevention measures aimed at curbing this epidemic. Research demonstrates that the etiology of obesity is complex and involves genetic, metabolic, environmental, social, and behavioral factors (6). To date, we know neither how these factors work to cause obesity nor how best to measure, treat or prevent it. Nevertheless, the public health and medical communities have been measuring obesity and have been working to treat and prevent it. Unfortunately, the majority of this work has relied on body mass index (BMI), a poor measure of obesity, and it has focused on just one aspect of the disease’s etiology, individual diet and exercise behaviors. One such intervention, undoubtedly doomed to failure, is the BMI Report Card.

In 2004, Arkansas initiated state legislation to mandate public elementary and secondary schools to include children’s BMI measurements on their report cards (7, 8). Since then, several states have followed suit, establishing programs to measure BMI in schools. If a child's BMI falls in the range considered to be “at risk for overweight” or “overweight” (according to the Centers for Disease Control BMI-for-age charts) then educational materials are sent home with the report card to help the family modify the child's diet and exercise (7). Additionally, parents are urged to seek advice from their family doctor about their child’s weight gain risks. Emphasizing that the BMI measurement is simply a screening test, similar to a vision or hearing test, health officials stress that families need to follow up with a doctor (7). Some criticism has been raised against the program, but there exists a severe lack of understanding regarding the full extent of the BMI Report Card's weaknesses and potential to cause harm.

BMI as a Measurement
To understand this issue, it is first necessary to explore the meaning of obesity and the history of BMI as a measurement. Obesity, which is defined as an excess accumulation of body fat, can be measured in a number of ways (9-11). The simplest and most common measure is BMI, which is calculated as an individual’s weight divided by the square of their height. This measure was first described by Adolphe Quitelet in the 19th century, and was later reinvented and dubbed BMI by Keys in the 1950s (12). It was most recently proposed for use in children by Cole in 1979 (12). In adults, BMI is divided into 5 categories: underweight, normal, overweight, obese, and morbidly obese. In children the raw BMI score is calculated the same as in adults (weight/height2), but then that score is ranked as a percentile in comparison to other children of the same sex and age. The CDC developed BMI-for-age charts based on data from the 2000 National Health and Nutrition Examination Survey (13). The charts divide BMI percentiles into four categories: underweight (<5th>95th percentile).

Though BMI has proved a useful tool for tracking obesity prevalence and incidence trends in populations, it is not a good measure of individual health risk. It has numerous limitations that make it a poor choice for screening individuals (10). For example, it is only a crude proxy for body fat and does not take into consideration muscle mass, bone structure or differences in body fat by ethnicity (14, 15). Additionally, in adults it does not account for sex or age. In children, the complications are even greater since body mass and fat mass change throughout development. These changes make it difficult to attribute a change in BMI to an increase in lean body mass or in fat mass (12). Athletes and others with a high percentage of muscle mass will have a high BMI. On the other hand, those with a normal BMI may still have excessive body fat, particularly if they have a small bone structure and low lean mass percentage. Using BMI as a screening tool means that some children may be falsely identified as overweight while many other children, those truly at risk, may be ignored (16). On a population level these misclassifications even out; on an individual level, they mean missed opportunities to treat children at risk for obesity. real mistakes in targeting children for treatment.

Another important factor to keep in mind when using BMI as a screening tool for obesity is that not all fat is created equally (17). According to a recent study in the European Journal of Endocrinology, “obesity does not necessarily imply disease and similarly obese individuals may manifest obesity-related morbidity or seemingly be in reasonably good health” (17). There is increasing evidence that adverse health outcomes are far more closely associated with central adiposity, or weight accumulated around the waist, than overall body fat (18). For example, cardiovascular disease risk is most associated with abdominal fat and the majority of current studies agree that waist circumference (WC) is probably a better indicator of abdominal fatness and cardiovascular disease risk than either BMI or waist-to-hip ratio (WHR) (19). This is because abdominal fat cells are metabolically different than other fat cells, releasing different amounts of hormones such as leptin and resistin (20). The more we learn about the connection between obesity and health, the more we realize how much there is yet to be understood. It is clear, though, that a simple measurement of weight adjusted by height is extremely limited in assessing individual risk of disease.

Relying on the Health Belief Model
Even if BMI were a perfect measure of health risk in individuals, the BMI Report Card would still fail because it relies on the Health Belief Model (HBM) to change individual behaviors. Though consistently ineffective, the HBM has been used time and again by the public health community since its development in the 1950s as a model to predict individual human behavior based on rational decision making (21). The HBM assumes that behavior is determined by an objective comparison of the perceived costs and benefits of a healthy behavior (21, 22). Following this model, an individual who is convinced of the severity of a disease and of their susceptibility to its health effects will adopt behaviors in order to avoid the disease (21, 22). An important aspect of this model is the assumption that one’s intention to do a behavior leads directly to that behavior being carried out.

The problem with the HBM is that it ignores the fact that people do not always make rational decisions, that they do not always carry out their intentions, and that there are real barriers to healthy behaviors beyond individual perception. In the case of the BMI Report Card, overweight and at risk children are targeted in order to improve their diets and increase their physical activity. Minimal assistance is given in helping children and families make these changes. Simply educating people about the need to exercise and eat healthily will not overcome barriers such as the availability of healthy foods, which varies between poor and affluent neighborhoods (23) or the lack of access to play grounds and organized sporting activities. It also does not address insufficient self efficacy, which is likely needed to make the changes.

Ignoring Social and Environmental Factors
Much of the blame for the obesity epidemic has been placed on an increasingly sedentary lifestyle and the ubiquity of fatty, processed foods that lack nutritional value (5, 11). While these two factors are largely societal in nature, the BMI Report Card and other interventions insist on focusing on individual behavior change. The very presence of an obesity epidemic, however, implies that there are important group level factors contributing to the problem. These factors may be lowered food quality across the population, reduced free time in a society where people routinely work multiple jobs, less physical activity in schools, the pervasiveness of televisions and computers, or even the presence of environmental contaminants capable of inducing obesity.

Obesity is extremely difficult, some would say impossible, to treat on an individual level. A review, published in 2007, of interventions to treat overweight adolescents found no evidence of clinically significant benefits (24). Another review of the same year studied treatments that involved parents and children together, that controlled exercise and diet and that promoted lifestyle changes. This review similarly found that there is limited quality data on the effects of obesity treatment programs and that “no generalisable conclusions can be drawn with confidence” (25). The BMI Report Card ignores this paucity of data and assumes that once overweight children are correctly identified, effective interventions are just a pamphlet away. Prevention of obesity is the best method to reduce current trends precisely because treatment is so difficult. In addition, treatment must be addressed through social and environmental factors, rather than individual behaviors. A 2005 review of prevention strategies for obesity in children reports that “practitioners need to consider the issues impacting on sustainability and environmental change whilst simultaneously addressing behavior change. The interventions identified in this review rarely consider the impact of parents and families’ increasingly complex working and living arrangements, yet the potential for change at the family level in the absence of addressing supportive strategies is likely to be diminished” (26). Unfortunately, the BMI
Report Card initiative ignores this advice.

Many scientists have come to the conclusion that, while social factors such as food quality and lifestyle are important, they are insufficient to fully explain the immense rise in obesity prevalence (6, 27). One interesting hypothesis is that exposure to certain compounds during critical periods of fetal development changes the pattern of gene expression within the DNA resulting in permanent alterations in appetite control, metabolic balance and fuel utilization (28, 29). In this regard, obesity may be less a cause of health outcomes and more like one symptom of a disease that also results in the long list of obesity-associated illnesses.

It is well established that patterns of gene expression are developed early in life, partly through a process of methylation of the DNA code, which essentially silences some genes and not others (28). This process is tightly regulated and orchestrated by minute chemical signals within the body (28, 29). Interference of these signals by compounds such as organotins (30) and bisphenol A (31) have been found to occur in mice, resulting in increased adipose tissue mass and serum cholesterol levels (31). Bisphenol A is a chemical known to leach from the lining of food cans and from polycarbonate plastic, which is used to make consumer products such as baby bottles. Research in this field is just beginning, but early results are strongly suggestive that these chemicals may play an important role in explaining the obesity epidemic.

Causing More Harm than Good
Considering the weaknesses inherent in using BMI as a measurement of obesity, as well as the indication that overall fat mass may not be an important determinant of health outcomes, it is clear that the BMI Report Card initiative is short sighted. While it’s true that having a high BMI as a child is associated with having a high BMI as an adult, screening for this characteristic may be meaningless if having a high BMI as an adult is not indicative of health risk. More importantly, the idea of basing an obesity intervention on changing individual diet and physical activity is completely misguided. Even if we were to assume that diet and exercise are the two most important risk factors for obesity—although, there is no evidence to confirm this—targeting individuals to change those behaviors, particularly through use of the Health Belief Model, will likely fail. It will fail because it’s not targeting the root cause(s) of the problem, which did not originate with individuals. Only an intervention targeting social and environmental factors is likely to be successful.

In light of these arguments, the BMI Report Card is bound to be a tremendous failure. One still might presume, though, that a little more education on diet and exercise and a little nudge in the right direction for overweight children and their parents can’t hurt. Unfortunately, this is far from true. Given that there is a longstanding epidemic of unhealthy body image among adolescents, increased pressure to lose weight and increased awareness of body size is likely to promote eating disorders and depression.

Cultural norms regarding acceptable body size result in body dissatisfaction for large numbers of women and men in the US. Psychological distress as well as discrimination in areas such as employment and healthcare are experienced daily by overweight and obese individuals (32, 33). In response to several studies documenting such mistreatment, Massachusetts is currently considering the addition of overweight and obese as categories in its employment anti-discrimination legislation (32).

Negative attitudes regarding fatness are adopted by children as young as five years old and studies report that preschoolers rank fat peers as the least desirable playmates (34). This negativity of young children towards fat playmates has increased markedly since the 1960s and research shows this rise to be due in part to a rise in antifat attitudes (34, 35). Antifat attitudes refer to the belief that overweight and obese individuals are responsible for their weight (36). Contrary to this popular notion, research strongly suggests that an individual’s weight is biologically programmed to stay within a certain 10-20 pound range. Moving outside of that range is extremely difficult; and maintaining a weight outside that range for an extended period of time is impossible for most people (32, 37, 38). These are biologic phenomena. And yet, antifat attitudes have risen, and with them, increased discrimination towards overweight and obese individuals.

Concerns about weight and body dissatisfaction are highly prevalent among adolescent girls and boys. In a California study, as much as 26% of boys and 35% of girls in the third grade reported wanting to lose weight (39). A troubling side-effect of such body dissatisfaction is actually poorer self-care. A study of 376 teen girls who were at or above the 85th percentile for BMI found that body satisfaction was protective against increased BMI (40). A previous study by the same authors found that lower body satisfaction predicted less physical activity and more unhealthy eating behaviors (40).

Interventions such as the BMI Report Card, in which children are measured and ranked, do not fare well for improving adolescent body image. Such interventions may in fact lead to worse diet and exercise behavior and, subsequently, poorer health outcomes for overweight children. Such programs also bolster the myth that if you’re fat, it’s your own fault. In a culture already obsessed with thinness, where fat people are shunned and discriminated against, the public health community has a responsibility to think carefully about interventions targeting obesity, particularly in sensitive populations such as children. The BMI Report Card fails in this regard, as well.

REFERENCES
1. Flegal KM. The obesity epidemic in children and adults: current evidence and research issues. Med Sci Sports Exerc 1999; 31(suppl):S509-S514.
2. Wang Y and Lobstein T. Worldwide trends in childhood overweight and obesity. Int J Pediatr Obes 2006; 1(1):11-25.
3. Hedley AA, Ogden CL, Johnson CL et al. Prevalence of overweight and obesity among US children, adolescents, and adults, 1999-2002. JAMA 2002; 291(23):2847-2850.
4. Ogden CL, Flegal KM, Carroll MD et al. Prevalence and trends in overweight among US children and adolescents, 1999-2000. JAMA 2002; 288(14):1728-1732.
5. World Health Organization. Obesity: preventing and managing a global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser 2000; 894:i-xi, 1-253.
6. Bray GA, Champagne CM. Beyond energy imbalance: there is more to obesity than kilocalories. J Am Diet Assoc 2005; 105(5, suppl 1):S17-S23.
7. Blome R. “In Arkansas report card, 'F' may stand for fat.” NBC News. July 20, 2004.
Rudd Center for Food Policy & Obesity. BMI Report Cards. Yale University 2005. http://www.yaleruddcenter.org/default.aspx?id=293.
9. Encyclopædia Britannica. "obesity." Encyclopædia Britannica Online. 17 Nov. 2007. http://www.britannica.com/eb/article-9056643.
10. Prentice AM and Jebb SA. Beyond body mass index. Obes Rev 2001; 2(3):141-7.
11. World Health Organization. Obesity and overweight. Fact Sheet No. 311, September 2006. http://www.who.int/mediacentre/factsheets/fs311/en/index.html.
12. Hall DM and Cole TJ. What use is the BMI? Arch Dis Child 2006; 91(4):283-6.
13. Centers for Disease Control. 2000 CDC Growth Charts: United States. Hyattsville, MD: National Center for Health Statistics. http://www.cdc.gov/growthcharts.
14. Freedman DS, Khan LK, Serdula MK et al. Racial differences in the tracking of childhood BMI to adulthood. Obesity Research 2005; 13(5):928-35.
15. World Health Organization expert consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 2004; 363(9403):157-63.
16. Reilly JJ, Dorosty AR and Emmett PM. Identification of the obese child: adequacy of the body mass index for clinical practice and epidemiology. Int J Obes Relat Metab Disord 2000; 24(12):1623-7.
17. Weiss R. Fat distribution and storage: how much, where, and how? Eur J Endocrinol 2007; 157(suppl 1):S39-45).
18. Yusuf S, Hawken S, Ounpuu S et al. Obesity and the risk of myocardial infarction in 27,000 participants from 52 countries: a case-control study. Lancet 2005; 366(9497):1640-9.
19. Dobbelsteyn CJ, Joffres MR, MacLean DR and Flowerdew G. A comparative evaluation of waist circumference, waist-to-hip ratio and body mass index as indicators of cardiovascular risk factors. The Canadian Heart Health Surveys. Int J Obes Relat Metab Disord 2001; 25(5):652-61.
20. Walker GE, Verti B, Marzullo P et al. Deep subcutaneous adipose tissue: a distinct abdominal adipose depot. Obesity (Silver Spring) 2007; 15(8):1933-43.
21. Salazar MK. Comparison of four behavioral theories. AAOHN Journal 1991; 39(3):128-135.
22. Edberg M. Essentials of health behavior: social and behavioral theory in public health. Sudbury, MA: Jones and Bartlett Publishers, Inc, 2007.
23. Powell Lm, Slater S, Mirtcheva D et al. Food store availability and neighborhood characteristics in the United States. Prev Med 2007; 44(3):196-7.
24. Whitlock EP, Williams SB, Gold R et al. Screening and interventions for childhood
overweight: a summary of evidence for the US Preventive Services Task Force. Pediatrics 2007; 116(1):e125-44.
25. Summerbell CD, Ashton V, Campbell KJ et al. Interventions for treating obesity in children. Cochrane Database Syst Rev 2003; (3):CD001872.
26. Summerbell CD, Waters E, Edmunds LD et al. Interventions for preventing obesity in children. Cochrane Database Syst Rev 2005; (3):CD001871.
27. Keith SW, Redden DT, Katzmarzyk PT et al. Putative contributors to the secular increase in obesity: exploring roads less traveled. Int J Obes (Lond) 2006; 30(11):1585-94.
28. Junien C and Nathanielsz P. Report on the IASO Stock Conference 2006: early and lifelong environmental epigenomic programming of metabolic syndrome, obesity an type II diabetes. Obes Rev 2007; 8(6):487-502.
29. Newbold RR, Padilla-Banks E, Snyder RJ et al. Developmental exposure to endocrine disruptors and the obesity epidemic. Reprod Toxicol 2007; 23:290-6.
30. Grün F and Blumberg B. Environmental obesogens: organotins and endocrine disruption via nuclear receptor signaling. Endocrinology 2006; 147(6)(Suppl):S50-S55.
31. Miyawaki J, Sakayama K, Kato H et al. Perinatal and postnatal exposure to bisphenol a increases adipose tissue mass and serum cholesterol level in mice. J Atheroscler Thromb 2007; 14(5):245-52.
32. Carmichael M. “Do we really need a law to protect fat workers?” Boston Globe. August 5, 2007.
33. Young-Hyman D, Tanofsky-Kraff M, Yanovski SZ et al. Psychological status and weight-related distress in overweight or at-risk-for-overweight children. Obesity 2006; 14(12):2249-58.
34. Latner JD and Stunkard AJ. Getting worse: the stigmatization of obese children. Obes Res 2003; 11(3):452-6.
35. Musher-Eizenman DR, Holub SC, Miller AB et al. Body size stigmatization in preschool children: the role of control attributions. J Pediatr Psychol 2004; 29(8):613-20.
36. Pepper AC and Ruiz SY. Acculturation’s influence on antifat attitudes, body image and eating behaviors. Eat Disord 2007; 15(5):427-47.
37. Taubes G. “The scientist and the stairmaster: why most of us believe that exercise makes us thinner—and why we're wrong.” New York Magazine. September 24, 2007.
38. Kolata G. Rethinking Thin: The New Science of Weight Loss — and the Myths and Realities of Dieting. New York, NY: Farrar, Straus & Giroux, 2007.
39. Robinson RN, Chang JY, Haydel KF and Killen JD. Overweight concerns and body dissatisfaction among third-grade children: the impacts of ethnicity and socioeconomic status. J Pediatr 2001; 138(2):181-7.
40. van den Berg P and Neumark-Sztainer D. Fat ‘n happy 5 years later: is it bad for overweight girls to like their bodies? J Adolesc Health 2007; 41(4):415-7.

Managed Care: The Role Of Deception In Health Outcomes – Jason Silver

Introduction: Managed Care
As renowned philosopher and ethicist Sissela Bok once wrote, “Trust and integrity are precious resources, easily squandered, hard to regain. They can thrive only on a foundation of respect for veracity.”(1) Although this statement serves as a valuable lesson that permeates everyday life, it transmogrifies into a grave warning when associated with the business of modern healthcare. This paper will explore the initial intent and subsequent failure of managed care as a public health intervention. Throughout the storied history of healthcare, there have been few interventions quite as controversial as the advent and implementation of managed care. While its roots take hold in the latter parts of the 19th century, managed care migrated to the forefront in the early 1990’s; it represented a response to an astronomical inflation of medical costs by proposing practices such as managing health care cases, implementing reviews assessing the medical necessity of services, and generating selective contracts with health care providers. However, managed care did not always have these goals in mind. A precursor to managed care, prepaid health services emerged in 1929, due in large part to the needs of countless rural residents and workers. This particular demographic lacked comprehensive health services despite the hazardous nature of their professions; the majority worked in lumber, mining, and railroad industries. The product, spearheaded by managed care pioneer Dr. Michael Shadid, was a rural farmers’ cooperative health plan in Elk City, Oklahoma in 1929; the members paid a predetermined fee and Dr. Shadid rendered his patient care. (2) As the novelty of affordable, comprehensive care moved west, a Dr. Sidney Garfield began providing similar prepaid services to roughly 5,000 aqueduct construction workers – by far the largest group of enrollees to this point. Garfield’s particular program was an evolutionary step forward from prior plans in that workers were now covered from possible accident cases as well as general care. With his success, Dr. Garfield extended his services five years later to the workers of the Grand Coulee Dam under Henry J. Kaiser. Kaiser became so enthused by the care his workers received, he expanded the idea further by setting up an additional two medical programs to provide comprehensive health services to workers in shipyards and steal mills during World War II. As the conflict came to an end, Kaiser opened his plans to the public in hope of reorganizing medical care to provide comprehensive, prepaid care that was also affordable. Within ten years, what was now known as the Kaiser Permanente Health Plan consisted of nearly half a million enrollees while boasting a growing network of hospitals and clinics throughout the West Coast.

Since then, many other prepaid group practice plans have developed and more recently have given way to what we know as the modern HMO Plan. By the 1990s, however, the makeup of healthcare changed dramatically, sprouting many new needs and organizational issues. For example, the cost of health insurance had increased dramatically. At the same time, health insurance had shifted from a traditional role of excellent fringe benefit to a new role of necessary entitlement. The aging of the population, more and better preventative medicine, new and expensive technology, administrative costs, significant numbers uninsured, and inefficient use of facilities and equipment all came together to create new, formidable obstacles to managing health care access and health care cost. (2) Now playing a new role in a more modern arena, managed care became the answer to uncontrollable cost increases and irrepressible inefficiency within the health care system. Despite the “shared commitment to comprehensive and coordinated healthcare” (3) that propelled the first ideas of pre-paid care, the modern revival of managed care as a public health intervention has not only failed to solve any of the current complications healthcare faces today, but has also led to a serious and steep decline in quality of patient care by way of unscrupulous, financially-bound ideals. One integral aspect of this misguided intervention that has caused much controversy is the fiscal relationship between providers and third party payers.

A Conflict of Interest and a Question of Ethics
When a particular system is flawed, it is always inevitable that those whom the system applies to will find ways to exploit its failings; in the case of managed care, “deception may be a symptom of a flawed system, in which physicians are asked to implement financing policies that conflict with their primary obligation to the patient.” (4) In fact, in recent studies, results have shown that a substantial proportion of physicians [reported] that they had deceived or would deceive third-party payers. (5) With these facts in mind, it is important to explore what exactly makes this system of payment bad enough to cheat. When asked why managed care settings are so difficult to deal with, the majority of physicians asked responded that “quality of health care is compromised by limitations in length of hospital stay and choice of specialists [among others].” (6) In other words, the care of any given patient is so micromanaged by limitations that oftentimes very little of what is necessary to care for them is unavailable. Further, what may be available becomes a long process of inefficient pre-authorizations due to administrative excess. Even more troubling is the complexion of the people behind the paperwork that makes managed care payments function; very few of those whom review patient cases have actual clinical experience beyond that which a textbook can provide. For this reason, relatively inexperienced personnel make judgments on access and subsequent reimbursement for thousands of patients and providers each year. These processes are direct results of growing desires to curb the cost of care by creating a system of checks and balances to providers. In fact, we find that physicians are being stripped of their authority to dictate proper care for their patients. Over the past few decades, the freedom enjoyed by physicians to judge and choose the ends of work has been increasingly challenged by both consumerism and managerialism, i.e., by the twin demands of competition and efficiency as embodied in the rise of managed care. (4) This increased interest in preserving cost at expense of care has left doctors with few options when negotiating the now complex course of care for their patients.

In a recent study analyzing physicians’ relationships with third party payers, it was noted that the dissonance between care and financing rules has become so severe that physicians see lying as the only way to do their jobs. (4) In fact, more and more physicians are finding more ways to deceive payers into approving what is perceived by providers as necessary care, a method called “gaming” the system. However, these manipulations do not reside in the realm of what we know as white lies. Physicians’ decisions about what services to offer their patients affect almost 80% of all health care expenditures and have enormous influence on health care quality. (7) Many small nuances oftentimes have a significant affect during any given provider-patient interaction; in fact, recent studies have shown that physicians regularly exaggerate the severity of their patient’s condition, alter diagnoses for billing purposes and even report symptoms that their patient may not have. Manipulations can be as discrete as changes in wording in medical records such as using “rule out cancer rather than screening” or as significant as creating nonexistent symptoms such as suicidal ideation to obtain a psychiatric referral. (8) This trend may lead to a better understanding of the reasoning behind this supposed deceit.

Morality in Deceit?
When physicians are asked to provide justification for what seems to be amoral behaviors, their answers reveal a desperate and failing attempt of the preservation of integrity within a system that is defined by deceit; some argue that manipulative or deceptive tactics can be justified by unfair or illegal rules and by burdensome paperwork while others insist that their deception stems from the unreasonableness of insurance companies and the strength of the physician’s obligation to patients. (9) It has even been suggested that some insurers are ‘gaming’ patients and physicians – tricking them into paying for covered services by routinely denying coverage but then approving services that are subsequently appealed, knowing that the time and other constraints will prevent some appeals. (5) In fact, just three years ago, a federal appeals court upheld a class-action lawsuit on behalf of physicians who charged that their patients’ insurance companies had conspired to curb reimbursement for the physicians’ services.(10) As evidenced by this 2004 ruling, the uselessness of managed care’s reimbursement system becomes increasingly prevalent as time wears on; the inconsistencies become increasingly exploited until a dangerous spiral forms in which each side is governed by their own stipulations in an attempt to fulfill disparate goals. This trickery has become so pervasive in health care today, that just last year the U.S. Department of Justice listed health care fraud as the second most pressing crime in the country, after crimes of violence. Such deceit has disastrous implications for patient care.

The Psychology, Sociology of Care
The quality of care any given patient receives depends heavily on complex relationships between doctors, payers, hospitals, and even the patient themselves. These connections are rooted deeply within several integral aspects of social and behavioral sciences. Several specific factors influence this balance, aside from the economic incentive, including psychological and sociological determinants. As an example, we know now that “the relationship between the charge generated by the chargemaster and the cost of service and what any given payer pays is tenuous at best, which creates the potential for a bad connection to spill over into many other essential fields of care. (11) For example, payment systems have historically not only failed to support collaboration between hospitals and doctors, they have discouraged it. (12) This tension between payers and payees has tainted the entire process of care for patients all over the country. Physicians are frustrated not only by the obstacles they face regarding reimbursement, but more importantly the hurdles they encounter when delegating the care of their patients. Physicians’ diminishing authority to dictate the correct amount of care has caused a backlash that extends not only to those in charge of paying, but the doctors’ employers as well. Although cooperation and collaboration between hospitals and physicians are key to achieving improvements in the quality of medical care delivery and outcomes, we are seeing an increased dissention between the two sides caused by increasingly disparate ideals within the framework of managed care. (12) However, perhaps the most important relationship in regard to quality of care is that between the provider and their patient.

The crooked evolution of managed care has put providers in an increasingly precarious position in which they become a middleman between the payer and the patient. Consumers of health care strive to find and create a relationship with their doctor based on honesty and integrity. However, despite this obvious necessity, roughly two-thirds of physicians surveyed in a recent study indicated that managed care has had a negative impact on that relationship. (6) Under managed care, doctors become a gatekeeper to medical services. In this role, the physician is viewed ambivalently; when positive, physicians are essential sources of knowledge that have the capability to guide their patients through the most productive route of care, however, when financial incentives are linked to medical decisions, the best route my be forsaken for one that is cheaper or produces more profit for other parties. In a recent study, it was found that gatekeeping had a negative affect on the physician-patient relationship, freedom in clinical decisions, time spent with patients, and ease of ordering expensive tests and procedures. (6)These findings paint a grim picture for the patient. Under the misaligned crux of managed care, essential interpersonal relationships are tainted to such an extent that unbiased, quality care is all but abandoned. Many other negative quality factors stem from this strain.

When providers are cornered into making compromising decisions, they often dangerously misrepresent their patient in hope of championing a better course of care for them. Although these offshoots of deception are often unintended, their impact can be devastating not only to the quality of the patient’s continuity of long-term care, but also to the integrity of epidemiological studies. For example, harm may come to patients if they receive unsuitable treatments or medications based on incorrect information provided on their medical record. (4) Epidemiological implications have the potential to adversely affect at the population level in such a way that misrepresented medical or health histories could be relied on as a methodological basis for new interventions to come. Just as important are the indications that just as “gatekeeping” puts the provider at a disadvantage in regard to his patient-provider relationship, so too does the act of deception. Patients may lose trust in the integrity of the medical profession when it becomes clear that the only way to achieve proper care is through trickery. Further, when fulfilling obligations to their patients, physicians are viewed to be allies of the patient, but when the physician is not able or unwilling to do what has now been established as the norm, the patient may question the trustworthiness of their doctor. The erosion of trust between a physician and their patient has a long sequence of potential issues; some include diminishing frequency of visits, unwillingness to follow through on doctor advice, or even making a change of provider. When provider turnover at the patient level is high, continuity of care is compromised. However, even more is at risk if the prior physician was untruthful in previous encounters. As one article states, “substantial harm may be done when lies of diagnosis, used to obtain coverage for a service, are inadvertently discovered by a patient.” (4) Altogether, while deception may seem to aid the patient in the instance of immediate care, there are many negative long-term implications that not only that patient may face, but the population could encounter as well. With so much attention paid to provider deception, these methods are not the only ways in which patient care suffers under managed care.

The Influence of Economics
Over the past decade, many general care facilities have suffered a mass exodus of specialty care physicians; this dissent has caused numerous catastrophic effects within the patient care facility setting. Physicians starting their own, privately funded specialty care facilities, they have the ability to “cherry pick” the more profitable patients from the general care facilities they once worked for. In fact, one Wall Street Journal Article describes how one general care hospital has been saddled with a monopoly on low-paying patients and services that hits the bottom line. For example, Medicare insurers pay a flay fee for many types of surgeries, regardless of the patient’s underlying health. Meanwhile, the article reveals that the specialty care facility in competition with this general care practice acknowledges it treats fewer complicated cases. (13) With upstart specialty care facilities siphoning the most profitable patients, many hospitals are left with the population of patients who are grossly underinsured or even worse, uninsured altogether.

This extreme competition has led to an equally extreme stratification of care in which privately insured patients enjoy the luxuries of specialty care facilities while those on federal aid or are uninsured face the prospect of finding care at a now endangered class of facilities. Countless corners have been cut at these facilities in order to keep up with their specialty care contemporaries. One such example explains how the competition between two hospitals has been especially fierce in neurosurgery. The general care facility has tried to fight back by recruiting a neurosurgeon not yet certified in the specialty. When the specialty care facility became aware of the fraudulent surgeon, they anonymously mailed letters to three of the surgeon’s patients, alleging their operations may have been botched. During trial, many of the plaintiffs revealed that the general care facility had protected the surgeon because it was under extreme competitive pressure to keep its doors open. (13) Although critics decry specialty hospitals for harming hospitals that serve poorer and sicker patients because they lead to inevitable waste of health care dollars, the success of these facilities illustrate how many doctors, feeling pressured by health insurers, have found new ways to prosper - now, in many cases - at the expense of the patient. (13) Hyper-competition from facilities born out of the frustration of many physicians have initiated a new trend toward a two-tiered care system in which poorer patients suffer from decreased access and quality, while the rich, privately insured patients enjoy extravagant, unneeded amenities inevitably leading to a waste in health care funding. Overall, evidence continues to mount that many unintended, but extremely problematic symptoms have stemmed from the implementation of managed care which have caused the intervention to flounder on achieving its main purposes.

Where Did It Go Wrong?
At its origin, the idea of pre-paid care was to protect a specific niche of society characterized by the obstacles they faced in regard to staying healthy. The design was simple, but more importantly, the people behind it were sincere in their goal to bring comprehensive, affordable healthcare to corners of this country that had yet to benefit from what it had to provide. However, as healthcare became more complicated, so did the system that supported it; pre-paid became HMO’s, which have come to epitomize the core of managed care. Now, instead of an idea, it has developed into an intervention to stop the hemorrhaging of the health care dollar, by creating an efficient business machine. Unfortunately, along the way, many people found fatal flaws in a system of managed care that has perhaps not kept pace with the ever-evolving business of health care. Medical decisions have become increasingly financially tied, with patient outcomes becoming a distant second priority. This emphasis on capital has not worked alone in the demise of managed care; in fact, the biggest failures of managed care can be explained within the theories of social and behavioral sciences.

As with any system, success depends heavily on the collaborative efforts of those enmeshed in it. In the case of managed care, this idea calls for insurers, providers, health care organizations, and the patient to work for common goals. With healthcare, this common ground can be an elusive plateau to reach. The first issue is authority; under managed care, the right of the proper medical decision has been stripped from the provider and transferred to the payer. This has led to an increase of administrative hurdles and a sense of frustration on the part of the doctor. With this premise, authorizations for care are made by people with relatively little clinical knowledge or background, whose goals are to pay as little as possible to the provider. This tenuous relationship between the provider and the payer influences the subsequent relationships the provider establishes with the facility which employs them and their patient. Primarily with the patient, the goal is trust. However, the mechanism of managed care makes openness difficult. Considering providers’ primary obligation is to their patient, they are put in a difficult position in which they must choose between deception and health outcome. Further, managed care has given rise to the role of gatekeeper that many physicians must fill. The idea behind gatekeeping stipulates that the doctor become the access point to any needed care; however, this role causes strain on the delicate relationship and fiduciary responsibility the provider has for their patient. The dangerous twist begins when deception gives way to mistrust in a way that each group acts under its own conditions; when this occurs, continuity and quality of care inevitably suffers.

When frustration boils over, doctors are forced into new roles as money-seekers, not able to procure it under the suppression of managed care. Providers turn to private practices that inevitably bleed hospitals of profitable patients, and leave access and quality of care just as stratified as it was before rural workers achieved care so long ago. In sum, there are countless reasons why managed care has failed as a modern public health intervention. Despite noble and pure intentions, what was once a novel way of managing health care has since withered into one of the biggest and most controversial failures of modern health care. The explanations behind the breakdown have been analyzed through the rhetoric of social and behavioral sciences by exploring a system in which its constituents must compromise integrity and responsibility to achieve positive health outcomes. We have seen that economics can play a decisive role in the interpersonal collaboration necessary to create a successful system, just as we have seen that system crack under unexpected exploitations, deception, and eventual mistrust. And we have seen that system fail at regulating cost and providing efficient care, as it was promised to achieve almost twenty years ago. It is understood that when it comes to health care, class trumps race. And reputation trumps everything. (14) Health officials today must look very closely at the wrong turns managed care have made and the subsequent implications of failure they have created, and wonder if this is the reputation we truly want health care to engender.

REFERENCES
1. Bok S. Lying: Moral Choice in Public and Private Life. New York, NY: Vintage Books; 1989

2. Tufts Managed Care Institute. A Brief History of Managed Care. Tufts Managed Care Institute, 1998.

3. Gilfillan, Sally W. Health Insurance in the 1990’s. The CPA Journal; Feb 1993:1-2

4. Bogardus, Sidney T. et al. Physicians’ Interactions With Third Party Payers (Is Deception Necessary?) Archives of Internal Medicine 2004; 164: 1

5. Wynia MK, Cummins DS, VanGeest JB, Wilson IB. Physician Manipulation of Reimbursement Rules for Patients: Between a Rock and a Hard Place. JAMA 2000; 283:1858-1865

6. Feldman, Debra S., MD, Novack, Dennis H., MD, Gracely, Edward, PhD. Effects of Managed Care on Physician-Patient Relationships, Quality of Care, and the Ethical Practice of Medicine. Archives of Internal Medicine 1998; 158:1

7. How Physician Organizations Are Responding to Managed Care. Washington DC: Center for Studying Health System Change 1999. Health System Change Issue Brief 20.

8. Novack DH, Detering BJ, Arnold R, Forrow L, Ladinsky M, Pezzullo JC. Physicians’ Attitudes Toward Using Deception to Resolve Difficult Ethical Problems. JAMA 1989; 261:2980-2985

9. Graber MA. Is it ethical to lie to secure hospital admission? Yes: lying is sometimes in the patient’s best interests. The Western Journal of Medicine 2001; 175:220

10. New England Journal of Medicine March 3, 2005

11. Becker, Cinda. Leading the Charge. Modern Healthcare 2007. Sept. 3:44-46.

12. Schulte, Margaret F. Editorial. Frontiers of Health Services Management 2007; 24:1 1-2.

13. Armstrong, David. A Surgeon Earns Riches, Enmity By Plucking Profitable Patients. The Wall Street Journal 2005. August 2: A1-A5.

14. Schulte, Brigid. Saving Lives, Losing Millions at Pr. George’s Hospital. Washington Post 2003. Dec. 22: A01.