Subscribe to the RSS feed.Raising Awareness About Rising Temperatures: An interview with State Epidemiologist Mel Kohn
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CHP | Posted on: September 14th, 2008
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On September 22, 2008, Dr. Mel Kohn, M.D., M.P.H, will serve as Acting Director of the Public Health Division and as State Health Officer until at least June 2009 while the Oregon Division of Human Services continues its search for a permanent director of the Public Health Division.
As Dr. Bruce Goldberg, Oregon DHS Director, said in a memo to DHS staff, “I chose Mel because I know he’s not interested in simply maintaining the status quo, but will continue to move the division forward as we strive to transform DHS into a world-class organization.”
Dr. Kohn has been Oregon’s State Epidemiologist and Administrator of the Office of Disease Prevention & Epidemiology since 2000. As Oregon’s public health representative on the State’s Global Warming commission, it has been his reponsibility to introduce public health implications into discussions and preparations for the impacts of global warming on Oregon. In this interview with Chris Palmedo, Dr. Kohn discussed global warming, as well as the important public health issues that currently face this state.
Before we talk about global warming, please tell us what you think are the most pressing epidemiological issues in Oregon right now?
Obesity is certainly at the top of the list. Also tobacco, which continues to be the leading preventable cause of death and disability. This is such a tragedy, because we clearly know what to do. If we just financed it properly, we could make major improvements in the health of Oregonians.
Are there other places that address tobacco effectively which serve as good models? New York City comes to my mind.
New York has been a leader around both tobacco and obesity. The states of Massachusetts and California also serve as good models. As I say, we know how to do it, but it is often a political battle to get it funded.
Oregon’s prevention program started in 1997 with a 30 cent-per pack tax increase. But only three of those 30 cents funded prevention while the rest was spent on medical care services. Nevertheless, those three cents added up to about $17 million per biennium and we did terrific things with those dollars. We saw twice the drop in tobacco use in Oregon that was seen in the rest of the country.
But in 2003, the state had a budget crisis, and our reward for what could have been the best outcomes of any program in state government was to slash our funding to about one-third of its original level. As a result, we’ve now seen an increase in smoking among pregnant women.
Suicide is also an important public health issue in Oregon. About three-fourths of the violent deaths in Oregon are from suicide, and we have very little infrastructure for reducing those numbers. As with other programs, we need to work on preventing suicide out in the communities.
There are certainly plenty of other challenges and lots of other good work to do, but obesity, tobacco use, and suicide are three of our top concerns.
Let’s talk about global warming and how you have been brought into the state’s efforts to prepare for and mitigate global warming?
A couple of years ago, I was asked to represent public health in the state’s Climate Change Integration Group. This was less than three years ago, and I was the first public health person to serve on this group.
At these meetings, I would ask about the health impacts of various climate change issues, and while everyone was intrigued and supportive, there were never a lot of clear answers. It eventually became clear to me that while the science was good on how many degrees of warming the planet would be expected to undergo, or how many feet of sea level rise we could expect to see as a result of ice cap melting, we didn’t know much about the health effects of warming temperatures.
What are the most serious health impacts from global warming facing Oregon?
Two of the most pressing issues are heat waves and forest fires. Most people don’t seem to appreciate how deadly heat waves can be. In 2003 a serious heat wave in Europe was estimated to have killed over 70,000 people. That’s a lot of people.
It turns out we know quite a bit about preventing these kinds of deaths. We know that the people most at risk have health conditions such as heart or lung disease, so a little heat stress can put them over the edge.
We also know that people who are socially isolated tend to be the ones who get hit hardest.
Those two factors together mean that the elderly are often at risk. Ultimately, we know that getting people into cool environments and getting information out are simple things we can do to prevent the quantity of widespread deaths we saw in Europe.
Not only is our overall population aging, but the Northwest can be expected to have a comparatively larger increase in elderly population in the coming years.
That’s right. This is going to be more and more of a problem. With climate change, the bell curve marking average temperatures will increase, but the curve will also spread, with the period of hot days expanding.
This issue has not been adequately addressed yet, and planning for these heat waves needs to happen at the local level. I can sit here in Portland and think about where people in Josephine County need to go, but that wouldn’t do much good. The people in Josephine County know the facilities, where the groups at risk are likely to be living, and how to best reach them.
The other issue is forest fires. We’re already seeing more forest fire activity. The situation this summer in California’s Central Valley has been very serious. Forest fire smoke is a very potent trigger for asthma. It can push people with chronic lung and heart disease over the edge. We’re going to see more and more smoke exposure, and again, we need to do a lot of planning at the local level.
Another issue is related to water. We’re going to see not only more water stress and drought, but also more severe weather events. And when you have a huge downpour, it washes contaminants into our water system.
A large portion of water borne diseases in the past fifteen years have been preceded by very high levels of rainfall – upwards of 80 percent of those outbreaks. So we need to consider this kind of data from a disease prevention point of view.
And locally, as we see less and less snow pack, we need to consider new ways to store and conserve water. In fact, we need to build these capabilities right now. While this may seem like bad news, there’s economic opportunity here. We have a lot of work to do in figuring out what needs to happen around water and putting those actions into place.
Oregon is one of the few states in the west that does not have a water agenda, and I’m hoping that will be put into place soon. While things are gearing up for the legislative session, a lot of it isn’t so much statutory as having a vision for where we want to go and knowing how to make that happen.
Obesity trends are also affected by temperature. When the weather changes, people’s physical activity patterns change. So promoting physical activity will be important to factor into our thinking.
On the other hand, a lot of the things we’re doing to prevent greenhouse gas emission have co-benefits in that they will encourage physical activity.
Such as when people get out of cars and start walking or riding bikes?
Exactly. That’s another really important issue for those working on climate change to get on board with.
Oregon has a lot of coastline. Do you see flooding as a public health risk?
Absolutely. Rising sea levels will have dramatic effects on coastal communities. There’s not a lot we can do locally to hold the sea back. It will rise.
Could that lead to stagnant water and water-borne illnesses?
We mostly worry about salt water infiltration into the aquifer which can degrade the quality of the water that’s available. That can be a very serious issue.
There are some substantial economic opportunities related to climate change that we need to be aware of. It may seem unlikely that someone in pubic health is talking about economic development, but we know that poverty and financial stress have adverse effects on health. If we can improve the economic environment, people’s health will also improve. We know economics affects family violence and interpersonal violence. We also know it affects health-related behaviors.
Those messages are a big part of the Community Health Priorities project.
As we move into the mitigation realm, preventing the emission of greenhouse gasses — developing wind power, developing solar power — a lot of that technology can happen here in Oregon. Research, development, and construction of these technologies could allow us to be a real powerhouse in this area. Part of this is allowing us to position ourselves to be able to take full advantage of those opportunities. Oregon is a perfect place to do that. We’re an environmentally aware and conscious state, and we’d be a great place to have those kinds of businesses.
You have had the opportunity to discuss these issues as a member of the State of Oregon’s climate change integration group.
The idea for this group was to be a place were the public and private sector, and different agencies in the pubic sector, could coordinate their efforts. This group developed ten recommendations for preparing for climate change, and one of those recommendations was to “incorporate the public health implications of climate change.”
The governor has recently appointed a global warming commission. I am the public health representative there, although other people, such as Andrea Durbin, represent various elements of public health.
Why is it important for human health, or public health, to be at the forefront of global warming discussions?
It’s important when we ask ourselves why people care, or should care, about climate change. They care about how it will touch their lives. We care about the environment for its own sake, but so many of us care about our own health and the health of our loved ones. These changes will have dramatic health effects and I hope that will be a motivator to get people engaged and galvanize the political will to make this happen.
Why has health not been at the forefront of global warming discussions?
It has to do with how we devalue public health concepts and issues across the country. The support we get from the state for our public health infrastructure is pretty minimal. The reason we have disease control and food borne outbreak programs is that we get federal money. We get almost no state investment there and it’s a huge problem. We don’t have the staff and we don’t always have the political clout to participate nationally.
I often think that participating in global warming committees has helped a little. But I still don’t have a staff for global warming-related preparation. We do have a policy option package that should move forward in the next session that will provide this department with actual people.
But how will we keep abreast of the science, how will we advance that science, and how will we integrate with the other players to do what needs to be done? For example, planning for heat waves and forest fires is a preparedness issue. How do we get that message into the preparedness program and competently staff it? It takes people, and part of the reason we haven’t been at the table is that we don’t have the resources to take action.
Are there some states that value health to the point that staffing is adequate?
We did a project here some time ago looking at what makes an excellent state health department. It was influenced by the book In Search of Excellence, and we studied four great health departments and sought to learn from them The four states we looked at were Washington, Massachusetts, Oklahoma, and North Carolina
One of the things we studied was the level of state investment in their public health infrastructure. In all of those places, it was at least in the 20-25% level and at the time we were at around 5%. So we took that as a reasonable benchmark for us to aim for in terms of where we ought to be.
Right now, Oregon is ranked around 43 out of 50 states in terms of expenditure.
We’re not very high, but those measurements can be deceiving. For example, in some places, environmental health are part of state health departments, awhile in others, they’re in natural resources. Some places include Medicaid, while others don’t. In Massachusetts, their number was around 70%, but much of that was in medical care. But still, we can do a lot better.
Health care policy is a popular topic in news and politics. Should public health play a larger role in health care policy? For example, when you look at presidential candidates’ “health care” proposals, aren’t they mostly talking about sickness insurance, which while important, is not the same thing as making our population healthier?
Absolutely. Of course we need good medical care, but what keeps people healthy is what happens in their environments around them. The medical care system doesn’t do much to promote health, but medical care has become such a large part of our economy — almost one of five dollars of our GNP. There’s less money available for all of the other kinds of public works activities, many of which, such as education, social services, and housing, impact the public’s health. Medical care is taking a lot of air out of the room, and when you add in military expenditures, there just isn’t a lot of money left over.
At the same time, we’re putting a lot of energy into health care reform, most of which is focused around changes in insurance structure and reimbursement, which is important…
But it’s about paying for disease, not promoting health.
Exactly, and we need to get a handle on the demand for those health care services. For example, if we don’t drive down the rates of obesity, any clever change we make to our health care system won’t change the fact that we’ll be swamped with an increase in need for those services. Along with seeking to better deliver health care services, we need to work up front to prevent the need for those services in the first place. And that’s where public health operates.
But for various reasons, our society doesn’t operate in a way that promotes the public’s health. And public health doesn’t seem to be adequately valued by society.
Part of it is cultural. Public health is a governmental activity and it’s largely a communal activity. It’s about what we do as a group to take care of each other.
The American mindset is very focused on individuals, individual responsibility, and individual choices. The minute the word government gets used, it often turns people off right away.
However, public health and individual choice are not incompatible. You can only make good choices if you have the information and the options to make those choices. What we need to do in public health is set up the environment so that more often, people will make the healthier choices.
So what can we do as advocates for a healthier society?
We need to value what public health offers, and resource it appropriately. From an advocacy point of view it means talking about what we do, like this project is doing. When most people think of health, they think of medical care, and we must get people to understand that health is about much more than medical care.
When a lot of people think of public health, they think of specific things, such as vaccinations, tobacco prevention, and communicable disease prevention, but they don’t necessarily think of it a global effort at promoting health for all.
For some reason, people do seem to look at the individual pieces, and miss the larger view of the public health fabric. Ultimately, we need to emphasize the important point that public health programs are among the most powerful tools for any society to promote and affect the health of everyone.
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