The population health argument against war.
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Comment↗
Biomedical subjects
Sandro Galea
Publications and source records attributed to Sandro Galea.
Period and birth-cohort effects on age of first phencyclidine (PCP) use among drug users in New York City, 1960 to 2000.
PURPOSE: The aim of the study is to determine period and birth-cohort effects in the early initiation of phencyclidine (PCP) use in drug users in New York City (NYC). METHODS: We analyzed data collected from two surveys of street-recruited drug users in NYC. We used survival analysis and proportional hazards modeling to assess period and birth-cohort effects on risk for early initiation of PCP use. RESULTS: Of 787 participants, 292 (37.1%) had used PCP by the age of 23 years. Before 1987, there was a greater risk for initiation of PCP use through the age of 23 years (hazard ratio [HR] = 34.77; 95% confidence interval [CI], 21.45-56.36). Proportional hazards modeling showed that those born in the 1971 to 1975 birth cohort compared with those born in 1976 to 1980 had a lower risk for initiation of PCP use through age 23 years (HR = 0.58; 95% CI, 0.37-0.91). Other significant predictors of PCP use by age 23 included white race and having been in a juvenile detention center. CONCLUSIONS: There are period and birth-cohort differences in the likelihood of early initiation of PCP use. Changes in drug culture and social norms may influence the likelihood of initiation of PCP use. This may have implications for interventions aimed at slowing the nationwide increase in use of PCP.
Adult↗
Optimizing telephone-based population sampling.
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Adolescent↗
Provision of naloxone to injection drug users as an overdose prevention strategy: early evidence from a pilot study in New York City.
INTRODUCTION: Naloxone, an opiate antagonist that can avert opiate overdose morality, has long been prescribed to drug users in Europe and in a few US cities. However, there has been little documented evidence of naloxone distribution programs and their feasibility in the peer reviewed literature in the US. METHODS: A pilot overdose prevention and reversal program was implemented in a New York City syringe exchange program. We assessed demographics, drug use, and overdose history, experience, and behavior at baseline, when participants returned for prescription refills, and 3 months after baseline assessment. RESULTS: 25 participants were recruited. 22 (88%) participants were successfully followed-up in the first 3 months; of these, 11 (50%) participants reported witnessing a total of 26 overdoses during the follow-up period. Among 17 most-recent overdoses witnessed, naloxone was administered 10 times; all persons who had naloxone administered lived. DISCUSSION: Naloxone administration by injection drug users is feasible as part of a comprehensive overdose prevention strategy and may be a practicable way to reduce overdose deaths on a larger scale.
Drug Overdose↗
Invited commentary: Considering bias in the assessment of respiratory symptoms among residents of Lower Manhattan following the events of September 11, 2001.
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Bias↗
Disasters and the health of urban populations.
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Disasters↗
Social and psychological resources and health outcomes after the World Trade Center disaster.
Previous studies on community disasters tend to assess non-representative samples and use nonstandard measures of well-being. Additionally, few of these studies are longitudinal in design. In this report, we examine the consequences of the World Trade Center Disaster (WTCD) within a stress model perspective to assess level of exposure to the disaster and well-being after this event, as measured by the SF12 mental health and physical health scales. Data come from a two-wave panel study of 1681 English or Spanish speaking adults living in New York City on the day of the terrorist attacks and were collected by telephone interviews 1 and 2 years after the disaster. In ordinary least-squares regression models that contained demographic characteristics, stress risk factors, and social psychological resources as independent variables, level of exposure to the disaster was associated with poorer Wave 2 physical well-being, but not psychological health. Level of disaster exposure was not related to Wave 2 physical health, however, once the Wave 1 level of physical health was controlled, suggesting that disaster exposure did not have a lasting impact on variation in physical well-being. Results also indicated that experiencing a panic attack, negative life events, or traumatic events were related to poorer physical health. Respondents who met screening criteria for possible alcohol dependence post-disaster, experienced negative life events, or experienced traumatic events, were more likely to suffer from poorer mental health compared to those who did not meet the criteria, experience negative life events or experience traumas. We discuss these findings relative to community disasters in industrialized and developing countries.
Adolescent↗
Alcohol use in New York after the terrorist attacks: a study of the effects of psychological trauma on drinking behavior.
Research has suggested that exposure to psychological trauma is associated with increased abuse of psychoactive substances, particularly alcohol. To assess this, we analyzed alcohol consumption, binge drinking, and alcohol dependence among a random sample of 1681 New York City adults 1 year and 2 years after the September 11 attacks. In multivariate models controlling for demographic factors, other stressor exposures, social psychological resources, and history of anti-social behavior, we found that greater exposure to the World Trade Center disaster (WTCD) was associated with greater alcohol consumption at 1 year and 2 years after this event. In addition, our analyses also indicated that exposure to the WTCD was associated with binge drinking at 1 year after but not 2 years after this event. Alcohol dependence, assessed as present in either year 1 or year 2, also was positively associated with greater WTCD exposures. Posttraumatic stress disorder was not associated with alcohol use, once WTCD exposure and other covariates were controlled. Our study suggests that exposure to psychological trauma may be associated with increases in problem drinking long after exposure and deserves further investigation.
Adaptation, Psychological↗
The effect of HIV infection on overdose mortality.
OBJECTIVES: To quantify the association of HIV infection with overdose mortality and explore the potential mechanisms. DESIGN: A prospective cohort study. METHODS: A total of 1927 actively injecting drug users who were HIV seronegative at baseline, of whom 308 later HIV seroconverted, were followed semi-annually for death from 1988 to 2001. Survival analyses using marginal structural and standard Cox models were used to evaluate the effect of HIV infection on the risk of overdose mortality. RESULTS: Overdose death rates were higher in HIV-seropositive than HIV-seronegative drug users: 13.9 and 5.6 per 1000 person-years, respectively (P < 0.01). The hazard ratio (HR) was 2.54 [95% confidence interval (CI) 1.47, 4.38] for the marginal structural model and 2.06 (95% CI 1.25, 3.38) for the standard Cox model, both adjusted for demographics, drug injection characteristics, alcohol abuse, substance abuse treatment, and sexual orientation. Adjusting for possible time-varying mediators (i.e. drug use, medical conditions and healthcare access) in extended marginal structural models reduced the effect of HIV on overdose mortality by 30% (HR 1.82, 95% CI 1.01, 3.30). Abnormal liver function was associated with a higher risk of overdose mortality (HR 2.00, 95% CI 1.05, 3.84); adjustment for this further reduced the effect of HIV on overdose mortality. CONCLUSION: HIV infection was associated with a higher risk of overdose mortality. Drug use behavior, systematic disease and liver damage associated with HIV infection appeared to account for a substantial portion of this association. The data suggest a group to target with interventions to reduce overdose mortality rates.
Adult↗
Effectiveness of highly active antiretroviral therapy among injection drug users with late-stage human immunodeficiency virus infection.
Highly active antiretroviral therapy (HAART) has been shown to be effective in different populations, but data among injection drug users are limited. Human immunodeficiency virus-infected injection drug users recruited into the Acquired Immunodeficiency Syndrome Link to Intravenous Experiences (ALIVE) Study as early as 1988 were tested semiannually to identify their first CD4-positive T-lymphocyte cell count below 200/microl; they were followed for mortality through 2002. Visits were categorized into the pre-HAART (before mid-1996) and the HAART eras and further categorized by HAART use. Survival analysis with staggered entry was used to evaluate the effect of HAART on acquired immunodeficiency syndrome-related mortality, adjusting for other medications and demographic, clinical, and behavioral factors. Among 665 participants, 258 died during 2,402 person-years of follow-up. Compared with survival in the pre-HAART era, survival in the HAART era was shown by multivariate analysis to be improved for both those who did and did not receive HAART (relative hazards = 0.06 and 0.33, respectively; p < 0.001). Inferences were unchanged after restricting analyses to data starting with 1993 and considerations of lead-time bias and human immunodeficiency viral load. The annual CD4-positive T-lymphocyte cell decline was less in untreated HAART-era participants than in pre-HAART-era participants (-10/microl vs. -37/microl, respectively), suggesting that changing indications for treatment may have contributed to improved survival and that analyses restricted to the HAART era probably underestimate HAART effectiveness.
Adult↗
Perspectives on urban conditions and population health.
The majority of the world's population will live in cities in the next few years and the pace of urbanization worldwide will continue to accelerate over the coming decades. While the number of megacities is projected to increase, the largest population growth is expected to be in cities of less than one million people. Such a dramatic demographic shift can be expected to have an impact on population health. Although there has been historic interest in how city living affects health, a cogent framework that enables systematic study of urban health across time and place has yet to emerge. Four alternate but complementary approaches to the study of urban health today are presented (urban health penalty, urban health advantage, urban sprawl, and an integrative urban conditions model) followed by three key questions that may help guide the study and practice of urban health in coming decades.
Cities↗
Association of sex, hygiene and drug equipment sharing with hepatitis C virus infection among non-injecting drug users in New York City.
BACKGROUND: Hepatitis C virus (HCV) rates are higher in non-injecting drug users (NIDUs) than general population estimates. Whether this elevated HCV rate is due to drug use or other putative risk behaviors remains unclear. METHODS: Recent non-injection drug users of heroin, crack and/or cocaine were street-recruited from 2000 to 2003 and underwent an interview and venipuncture for HCV antibody assays. Multiple logistic regression analyses were used to assess correlates for HCV infection. RESULTS: Of 740 enrollees, 3.9% were HCV positive. The median age (intraquartile range) was 30 (35-24) years, 70% were male and 90% were Black or Hispanic. After adjustment, HCV seropositives were significantly more likely than seronegatives to be older than 30 [adjusted odds ratio (AOR)=5.71], tattooed by a friend/relative/acquaintance [AOR=3.61] and know someone with HCV [AOR=4.29], but were less likely to have shared nail or hair clippers, razors or a toothbrush [AOR=0.32]. CONCLUSIONS: Non-commercial tattooing may be a mode of HCV transmission among NIDUs and education on the potential risk in using non-sterile tattooing equipment should be targeted toward this population. While no evidence was found for HCV transmission through NIDU equipment sharing or sexual risk behavior, further research is still warranted.
Adult↗
A comparison of HIV seropositive and seronegative young adult heroin- and cocaine-using men who have sex with men in New York City, 2000-2003.
The purpose of this analysis was to determine the prevalence and correlates of HIV infection among a street-recruited sample of heroin- and cocaine-using men who have sex with men (MSM). Injection (injecting <or=3 years) and non-injection drug users (heroin, crack, and/or cocaine use <10 years) between 18 and 40 years of age were simultaneously street-recruited into two cohort studies in New York City, 2000-2003, by using identical recruitment techniques. Baseline data collected among young adult men who either identified as gay/bisexual or reported ever having sex with a man were used for this analysis. Nonparametric statistics guided interpretation. Of 95 heroin/ cocaine-using MSM, 25.3% tested HIV seropositive with 75% reporting a previous HIV diagnosis. The majority was black (46%) or Hispanic (44%), and the median age was 28 years (range 18-40). HIV-seropositive MSM were more likely than seronegatives to be older and to have an HIV-seropositive partner but less likely to report current homelessness, illegal income, heterosexual identity, multiple sex partners, female partners, and sex for money/drug partners than seronegatives. These data indicate high HIV prevalence among street-recruited, drug-using MSM compared with other injection drug use (IDU) subgroups and drug-using MSM; however, lower risk behaviors were found among HIV seropositives compared with seronegatives. Large-scale studies among illicit drug-using MSM from more marginalized neighborhoods are warranted.
Adolescent↗
Circumstances of witnessed drug overdose in New York City: implications for intervention.
Drug users frequently witness the nonfatal and fatal drug overdoses of their peers, but often fail to intervene effectively to reduce morbidity and mortality. We assessed the circumstances of witnessed heroin-related overdoses in New York City (NYC) among a predominantly minority population of drug users. Among 1184 heroin, crack, and cocaine users interviewed between November 2001 and February 2004, 672 (56.8%) had witnessed at least one nonfatal or fatal heroin-related overdose. Of those, 444 (67.7%) reported that they or someone else present called for medical help for the overdose victim at the last witnessed overdose. In multivariable models, the respondent never having had an overdose her/himself and the witnessed overdose occurring in a public place were associated with the likelihood of calling for medical help. Fear of police response was the most commonly cited reason for not calling or delaying before calling for help (52.2%). Attempts to revive the overdose victim through physical stimulation (e.g., applying ice, causing pain) were reported by 59.7% of respondents, while first aid measures were attempted in only 11.9% of events. Efforts to equip drug users to manage overdoses effectively, including training in first aid and the provision of naloxone, and the reduction of police involvement at overdose events may have a substantial impact on overdose-related morbidity and mortality.
Adolescent↗
A model of underlying socioeconomic vulnerability in human populations: evidence from variability in population health and implications for public health.
Drawing from insights into the variability of complex biologic systems we propose that the health of human populations reflects the interrelationship between underlying vulnerabilities (determined by population-level social and economic factors; e.g., income distribution) and capacities (determined by population-level salutary resources, e.g., social capital) and how populations, shaped by these vulnerabilities and capacities, respond to intermittent stressors (e.g., economic downturns) and protective events (e.g., introduction of a school). Monitoring this dynamic at the population-level can be accomplished by examining not only rates of illness and mortality, but variability in rates, either between populations or within populations over time. We used mortality data from New York City neighborhoods between 1990 and 2001 to test two related hypotheses consistent with this model of population health: (a) There is greater variability in mortality rates at a point in time between neighborhoods that are characterized by socioeconomic vulnerability; and (b) there is greater variability in mortality rates over time within neighborhoods that are characterized by socioeconomic vulnerability. We found that neighborhoods characterized by social and economic vulnerability displayed substantial variability in particular mortality rates. Mortality rates displaying the greatest variability were from causes that may be sensitive to social conditions (e.g., homicide or HIV/AIDS rates). Variability in population health existed both between neighborhoods with underlying vulnerability at one point in time and within vulnerable neighborhoods over time. The results of this analysis are consistent with a theory of underlying socioeconomic vulnerabilities of human populations and suggest that variability in population health may be an important consideration in population health assessment.
Health Status Indicators↗
Disparities in mental health treatment following the World Trade Center Disaster: implications for mental health care and health services research.
To assess disparities in mental health treatment in New York City (NYC) after the World Trade Center Disaster (WTCD) reported previously related to care access, we conducted analyses among a cross-sectional survey of adults who had posttraumatic stress disorder (PTSD) or major depression (N = 473) one year after the event. The dependent variables examined were use of mental health services, in general, and use of mental health services related to the WTCD. Similar dependent variables were developed for medication usage. Although a number of bivariate results were statistically significant for postdisaster mental health visits, in a multivariate logistic regression model, only WTCD exposure remained significant. For service utilization related to the WTCD, the multivariate results indicated that African Americans were less likely to have had these visits compared to Whites, while those with a regular doctor, who had greater exposure to WTCD events, and those who had a perievent panic attack were more likely to have had such visits. In terms of medication use, multivariate results suggested that African Americans were less likely to use postdisaster medications, whereas persons 45 + years old and those with a regular doctor, were more likely to use them. For WTCD-related medication use, multivariate models indicated that African Americans were less likely to use medications, relative to Whites, while those between 45 and 64 years old, those with a regular doctor, those exposed to more WTCD events, and those who had a perievent panic attack, were more likely to have taken medications related to the disaster. The primary reason respondents gave for not seeking treatment (55% of subsample) was that they did not believe that they had a problem (73%). Other reasons were that they wanted to solve the problem on their own (5%), had problems accessing services (6%), had financial problems (4%), or had a fear of treatment (4%). Despite the availability of free mental health services offered in a supportive and potentially less stigmatizing environment post disaster, there still appeared to be barriers to receiving postdisaster services among those presumably in need of care.
Health Services Needs and Demand↗
Participant reactions to survey research in the general population after terrorist attacks.
There remains concern that survey research after a disaster can precipitate or exacerbate distress among study participants. The authors surveyed 5,774 persons in three random-digit-dial telephone surveys of the general population of New York City conducted 1-2 months, 4-5 months, and 6-9 months after the terrorist attack on September 11, 2001. Overall, 746 (12.9%) people who finished the surveys said that the survey questions were upsetting but only 57 (1.0% overall) were still upset at the end of the interview, and 19 (0.3%) wanted assistance from a counselor. Ten persons who did not finish the survey also received counselor assistance. Persons with mental health symptoms were more likely to find the survey questions emotionally upsetting as were participants who lacked salutary resources, including health insurance and a regular health care provider. Although relatively few of those interviewed found the survey assessment disturbing, the presence of a small number of respondents who wanted mental health assistance suggests the need for a mental health backup system for research conducted soon after exposure to large-scale traumatic events.
Demography↗
Beyond urban penalty and urban sprawl: back to living conditions as the focus of urban health.
Researchers have long studied urban health, both to describe the consequences of urban living and to design interventions to promote the health of people living in cities. Two approaches to understanding the impact of cities on health have been dominant, namely, urban health penalty and urban sprawl. The urban penalty approach posits that cities concentrate poor people and expose them to unhealthy physical and social environments. Urban sprawl focuses on the adverse health and environmental effects of urban growth into outlying areas. We propose a model that integrates these approaches and emphasizes urban living conditions as the primary determinant of health. The aim of the model is to move beyond describing the health-related characteristics of various urban populations towards identifying opportunities for intervention. Such a shift in framework enables meaningful comparisons that can inform public health activities at the appropriate level and evaluate their effectiveness in improving the health of urban populations. The model is illustrated with two examples from current urban public health practice.
Community Health Services↗