Monthly Archives: May 2011

Academia, Emergency Management, Health Care, Public Health, Society

Public Health Risks in the 21st Century

Within the next 30 years, I foresee a significant public health risk of viral pandemic, a concern outlined in the recently published CISIS commission report (Fallon & Gayle, 2010). According to many, the next significant pandemic to be a global threat will occur anytime between now and 70 years (Gostin, 2004; Monto, Comanor, Shay, & Thompson, 2006; Ravilious, 2005; Smil, 2008; Tapper, 2006; Taubenberger, Morens, & Fauci, 2007). Although many scientists have their focus on influenza as the most probable for pandemic exposure, other novel virii, such as SARS, HIV, et al., have the facets to make them just as potentially significant (Gostin, 2004; Smil, 2008; Tapper, 2006). Regardless of the particular pathogen, history has shown pandemics to create and environment of negative net effects to humanity. According to Billings (1997) and Ravilious (2005), the Spanish influenza pandemic of 1918, caused by a mutated avian flu strain, claimed between 20-million and 40-million lives in a single year (Monto et al., 2006; Taubenberger et al., 2007). Spreading quickly along major international trade routes, the Spanish flu infected many servicemen returning from duty at the end of World War I. As these infected servicemen returned and celebrated the armistice in crowds of people, a severe strain on the public health system in the United States was unknowingly developing. Considering the hypervirilence and increased mortality (2.5%, compared to the typical 0.1%) caused by the 1918 Spaish flu, the world’s economy was in turmoil (Billings, 1997). As most of the American workforce was recently embroiled in overseas combat duty, upon their return they must now face the possibility of infection, an inability to work, and possible death.

Monto et al. (2006) outline a useful model of surveillance techniques that would not only be useful in detecting and improving response to influenza outbreaks, but it would certainly help to detect any new significant diseases that could be a public health risk and threaten a population or society. Additionally, Taubenberger et al. (2007) focuses on learning the biology of the influenza virus to predict the possibility of outbreak and, thus, pandemic potential. Coupling these two approaches makes sense to both identify potential pathogens and use surveillance techniques to track and direct responses to mitigate actual outbreaks as they occur. These efforts, however, should be directed by an organization that values independant operation, impartiality, neutrality, and universality, just a few of the principles of the Red Cross and Red Crescent movements (International Federation of Red Cross and Red Crescent Societies, 2010). Adoption of these principles will allow valuable health information to flow freely to other entities positioned to respond appropriately without regard to local politics, ensuring a just and equitable solution to help to mitigate the potential for great harm.

References

Billings, M. (1997/2005). The influenza pandemic of 1918. Retrieved from http://virus.stanford.edu/uda/

Fallon, W. J. & Gayle, H. D. (2010). Report of the CISIS commission on smart global health policy: A healthier, safer and more prosperous world. Washington, DC: Center for Strategic & International Studies.

Gostin, L. O. (2004). Pandemic influenza: Public health preparedness for the next global health emergency. The Journal of Law, Medicine & Ethics, 32(4), 565-573. doi:10.1111/j.1748-720X.2004.tb01962.x

International Federation of Red Cross and Red Crescent Societies. (2010, July). Haiti: From sustaining lives to sustainable solutions – the challenge of sanitation. Geneva, Switzerland: Author.

Monto, A. S., Comanor, L., Shay, D. K., & Thompson, W. W. (2006). Epidemiology of pandemic influenza: use of surveillance and modeling for pandemic preparedness. Journal of Infectious Diseases, 194(Suppl. 2), S92-S97. doi:10.1086/507559

Ravilious, K. (2005, April 14). What a way to go. The Guardian. Retrieved from http://www.guardian.co.uk/science/2005/apr/14/research.science2

Smil, V. (2008). Global catastrophes and trends: the next fifty years. Cambridge, MA: The MIT Press.

Tapper, M. L. (2006). Emerging viral diseases and infectious disease risks. Haemophilia, 12(Suppl. 1), 3–7. doi:10.1111/j.1365-2516.2006.01194.x

Taubenberger, J. K., Morens, D. M., & Fauci, A. S. (2007). The next influenza pandemic: Can it be predicted? Journal of the American Medical Association, 297(18), 2025–2027. doi:10.1001/jama.297.18.2025.

Academia, Health Care, Public Health

A Novel Approach to Combat Heart Disease

According to Hansson (2005), cardiovascular disease is fast becoming the number one killer in the world among in developing countries and the Western world, due mainly to the correlation of increased rates of obesity and diabetes (Haffner, Lehto, Rönnemaa, Pyörälä, & Laakso, 1998; Miller, 2011; Willer et al., 2008). The goal of eradicating heart disease by the end of the twentieth century has been missed as cardiovascular disease is still responsible for 38% of deaths in North America. There has been much research over the last three decades regarding correlations between cardiovascular disease, obesity, and diabetes. Miller et al. (2011) identifies, based on the current literature, a number of metabolic syndromes in which elevated triglyceride levels are responsible for significantly increasing the risk of cardiovascular disease and the risk of death from a cardiac event.

Risk factors for cardiovascular disease, including smoking, hypercholesterolemia, and diabetes, which have positive predictive value for CVD, include a positive family history, hypertension, male gender, and age (Haffner, Lehto, Rönnemaa, Pyörälä, & Laakso, 1998; Hansson, 2005; Koliaki, 2011).

Demographically, according to NHANES 1999-2008 (as cited in Miller, 2011), Mexican American men (50 to 59 years old, 58.8%) are at the greatest risk with the highest prevalence of elevated triglyceride levels ( 150 mg/dL) followed by (in order of decreasing prevalence) Mexican American women ( 70 years old, 50.5%), non-Hispanic White men (60 to 69 years old, 43.6%), non-Hispanic White women (60 to 69 years old, 42.2%), non-Hispanic Black men (40 to 49 years old, 30.4%), and non-Hispanic Black women (60 to 69 years old, 25.3%).

Haffner et al. (1998) describe the importance of lowering cholesterol levels in those with diabetes mellitus type II as they both contribute to increases in mortality and morbidity from cardiovascular disease; therefore, efforts should be focused on identifying risks to heart health starting at age 30 with concomitant risk factors of diabetes or dyslipidemia, or any combination of two or more identified risk factors. More specific screening should begin at age 40 with Mexican American males and all other demographics suffering from any one of the secondary risk-factors, and at age 50 with all other ethnic demographics, regardless of the presence of risk-factors.

Specific screening for the at-risk population should include diagnostic percutaneous transthoracic coronary angiography (PTCA) and angioplasty, if needed. PTCA is a method of introducing a catheter through an artery to the coronary arteries of the heart, guided by radiology, to diagnose specific narrowing of these vessels, at which time a repair (angioplasty) can proceed immediately. PTCA, according to Koliaki et al. (2011), is the gold standard of diagnosing the presence and degree of atherosclerotic CVD. Currently, the standard for initiating PTCA requires a more acute presentation, typically complaints of chest pain or some other cardiac related illness. However, the proven safety and efficacy of PTCA may allow it to be used more as a screening tool as well as a primary coronary intervention in acute cases.

Utilizing the diffusions of innovations model of behavior change, public health entities can provide specific information to encourage interventional cardiologists to employ this technique as a focused CVD screening tool for at-risk populations (“Culture and health,” 2012). Adoption, however, is conditional on remuneration; therefore, a public health task force at the national level should investigate the potential for spending versus savings, and if significant, should disseminate the information to third-party payors (heath insurance providers, etc.) to ensure coverage when required. Additionally, grassroots efforts should be two-pronged, focusing on both the affected communities and the physicians most likely to contact the at-risk community. For the at-risk community, using mass-media, the message should simply be to discuss your risk with your physician, stop smoking, eat healthy, and exercise. The message, itself, needs to be conveyed in an effective manner, however. For the physicians, using mass-mailing and professional development campaigns, the message needs to more complex outlining risk versus reward, cost-effectiveness, and the potential for impacting a growing trend of heart-related death and disability. The American Heart Association has a proven track record of effective mass-media campaigns as well as professional development programs. So long as PTCA can be considered as an effective and cost-saving screening tool, the American Heart Association should certainly be involved in sending the message out.

Like with the proliferation of television advertisement of pharmaceuticals, using diffusions of innovations, we can get the heart-healthy message to the communities that would most benefit and the providers who can facilitate appropriate and novel screening and treatment techniques. We have already failed to eradicate CVD by the turn of the century, but if we think outside the box and develop novel approaches to consider, we may still have a chance at effectively lowering the incidence and prevalence of CVD in the years to come.

References

Culture and health. (2012). Public health and global essentials (Custom ed.; pp. 213-226). Sudbury, MA: Jones & Bartlett.

Haffner, S. M., Lehto, S., Rönnemaa, T., Pyörälä, K., & Laakso, M. (1998). Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. New England Journal of Medicine, 339(4), 229-234. doi:10.1056/NEJM199807233390404

Hansson, G. K. (2005). Inflammation, atherosclerosis, and coronary artery disease. New England Journal of Medicine, 352(16), 1685-1695. doi:10.1056/NEJMra043430

Koliaki, C., Sanidas, E., Dalianis, N., Panagiotakos, D., Papadopoulos, D., Votteas, V., & Katsilambros, N. (2011). Relationship between established cardiovascular risk factors and specific coronary angiographic findings in a large cohort of Greek catheterized patients. Angiology, 62(1), 74-80. doi:10.1177/0003319710370960

Miller, M., Stone, N. J., Ballantyne, C., Bittner, V., Criqui, M. H., Henry N. Ginsberg, H. N., … Council on the Kidney in Cardiovascular Disease (2011). Triglycerides and cardiovascular disease: A scientific statement from the American Heart Association. Circulation, 123(20), 2292-2333. doi:10.1161/CIR.0b013e3182160726

Willer, C. J., Sanna, S., Jackson, A. U., Scuteri, A., Bonnycastle, L. L., Clarke, R., … Abecasis, G. R. (2008). Newly identified loci that influence lipid concentrations and risk of coronary artery disease. Nature, 40(2), 161-169. doi:10.1038/ng.76

Appendix

P.E.R.I. Problem Identification

The health problem I have identified is cardiovascular disease (CVD). According to Hansson (2005), CVD was expected to be significantly reduced or eliminated by the turn of the century; however, cardiovascular disease remains one of the leading cause of death globally with a rise in obesity and diabetes incidence (Willer et al., 2008). The two primary factors contributing to CVD are thought to be hypercholesterolemia, or high cholesterol levels in the blood, and hypertension, or high blood pressure, and although Koliaki et al. (2011) shows no predictive value between obesity and CVD, there remains a strong correlation between obesity and diabetes (Haffner, Lehto, Rönnemaa, Pyörälä, & Laakso, 1998; Hansson, 2005). A better look at the emerging literature might provide insight as to why attempts to control cholesterol and blood pressure have largely failed to eradicate CVD.

Koliaki et al. (2011) contend that smoking, hypercholesterolemia, and diabetes have positive predictive value for CVD while a positive family history, hypertension, male gender, and age, though predictive, are significantly less specific. Considering the causative risk factors and admitting the difficulty in changing age, family history, and gender, altering smoking status, cholesterol levels, and severity of diabetes and blood pressure have all been shown to decrease the risk of CVD. However, like genetic factors such as family history and gender, researchers are finding difficulty in controlling cholesterol levels effectively in many patients, especially those with concommitant diabetes mellitus (Haffner et al., 1998; Willer, 2008). However, statin-type cholesterol-lowering medications appear to have other protective effects than merely lowering cholesterol (Hansson, 2005).

In order to combat the growing concern of cardiovascular disease and, ultimately, the increasing mortality from the same, the American Heart Association (AHA) has published a scientific statement paper regarding the latest literature and research (Miller et al., 2011). AHA has taken the lead in cardiovascular health and strives to promote best practices based on the available evidence. By promoting AHA’s position using mass-mailing campaigns to physicians practicing in primary care, emergency, cardiology, and endocrinology, we can be assured that the right message is being disseminated rapidly to those most inclined to intervene. As more physicans in the identified roles adopt the latest evidence-based practice, more at-risk patients can be screened for CVD and the contributing factors. As screening paradigms become more focused, more of the at-risk population will be identified sooner which will allow for earlier intervention decreasing overall mortality and morbidity from CVD.

P cardiovascular disease
E Causes: DM, type II; dyslipidemia (hypercholesterolemia); smoking; diet; exercise; gender; age
Burden: increasing mortality and morbidity globally
R Diabetes mellitus screening and control, HTN screening and control, statin-type medication prescription, PTCA screening recommendations, smoking cessation
I AHA position, public health mailing campaign, cadre of physician groups
Academia, Health Care, Public Health, Society

Leadership & Character

Juxtaposing Two Renowned Leaders of Health

When considering leadership in health care, I think first of how that leadership has affected health care in particular. Being a leader in health care does not guarantee great impact; however, an effective leader can have great impact over a large scope. This is how I framed my search to find two leaders in health care to highlight in this paper.

The first leader of health care that I will discuss is Clara Barton. According to Chambers (2002), Barton, independent to a fault, has been described as having a persuasive power about her. A fairly timid girl, Barton had self-image problems growing up that were at times debilitating; however, it seemed that as long as her interest was in helping others Barton performed selflessly, with heroism and bravado usually reserved for men during the time. Barton, a school teacher, found herself in the middle of the Civil War caring and tending to the soldiers on the battlefield. Dubbed the angel of the battlefield, Barton would not cease in caring for the soldiers even under enemy fire.

Barton, according to Chambers (2002) was not a very effective manager, but she could convince anyone to do anything that she needed to get done, it was said. Barton presents with a leadership style that is transformational (Robbins & Judge, 2010). She sees a need and immediately works to fill the void, inspiring others to do the same. Barton was ultimately responsible for founding the American Red Cross, a neutral organization that today responds to over 67, 000 disasters per year providing medical supplies, food, and housing in order to promote health equity even during wartime. Barton was a socialized charismatic leader, and her accomplishments are truly inspirational (Robbins & Judge, 2010).

The second leader of health care, more so in death than in life, that I chose to discuss is Johns Hopkins. Most people are familiar with Johns Hopkins Hospital and Johns Hopkins University, but it might be surprising to know that these namesakes were only made possible by the posthumous gift of $7-million from Hopkins’s estate (Herringshaw, 1901; “Johns Hopkins,” 1891). Hopkins started life from an affluent family, but a choice to free the family’s slaves forced Hopkins out of his formal education to help on the family tobacco farm. Since leaving the family farm, it seemed, by all accounts, that Hopkins had an innate ability for business (“Johns Hopkins,” 1891). Hopkins became very successful in business early in his lifetime, and he always tried to return his good fortune to the community. This innate ability for business, along with his unwavering business ethics, would seem to make Hopkins a likable and well-respected leader, possibly invoking a sense that he was born with these traits (Borgatta, Bales, & Couch, 1954; Cawthon, 1996; Robbins & Judge, 2010). It was in the spirit of community leader that Hopkins fulfilled his final philanthropy by funding an orphanage, a university, colleges, and a hospital that to this day is world-renowned. Johns Hopkins was an authentic leader (Robbins & Judge, 2010).

Whether a leader is naturally born with certain traits or learns behaviors from their environment, what matters most is that they be prepared to lead when the time comes. Without the onus of personal responsibility, no true leaders can exist.

References

Borgatta, E. F., Bales, R. F., & Couch, A. S. (1954). Some findings relevent to the great man theory of leadership. American Sociological Review, 19(6), 755-759. doi:10.2307/2087923

Cawthon, D. L. (1996). Leadership: the great man theory revisited. Business Horizons, 39(3), 1-4. doi:10.1016/S0007-6813(96)90001-4

Chambers, L. (2002). Fearless under fire. Biography, 6(4), 64-67, 96-97.

Herringshaw, T. W. (Ed.). (1901). Johns Hopkins. Herringshaw’s encyclopedia of American biography of the nineteenth century. Retrieved from http://books.google.com/

Johns Hopkins. (1891). The national cyclopaedia of American biography (Vol. 5). Retrieved from http://books.google.com/

Robbins, S. P. & Judge, T. A. (2010). Leadership. Essentials of Organizational Behavior (pp. 159-180). Upper Saddle River, NJ: Pearson Prentice Hall.

Academia

Theories of Motivation

Perhaps, one of the most difficult aspects of managing human resources is understanding the motivational factors present that promote or inhibit work product. I believe it is also difficult for managers to take inventory of their own motivational factors. I will discuss some of the major motivational theories and apply them to a hypothetical scenario. The scenario portends to be a synopsis of Susan Smith’s typical day. Susan is a Human Resource Manager at a health care provider and must manage both the employees’ and her own priorities.

One of the founding theories of motivation is Maslow’s heirarchy of needs (Banerjee, 1995; Maslow, 1943; Robbins & Judge, 2010). In it, Maslow describes how people prioritize needs based on the weighted fulfillment of those needs; ergo, a starving man may kill for food, yet may not if he is also acutely dehydrated. This example demonstrates that although the starving man might not kill normally, he may in order to combat the physiologic need of hunger to survive. This hunger can be shadowed, however, by a lower-order physiologic need of thirst which will mute the desire to fulfill the food craving while in search or water. Maslow’s heirarchy includes (from lowest-order to highest-order): 1) physiologic, 2) safety, 3) social, 4) esteem, and 5) self-actualization needs.

In this scenario, Susan is confronted with the stress of fulfilling her job and meeting her deadlines. This could trigger a want of fulfilling safety needs if she feels that her livelihood is threatened. These needs are motivating Susan to stay late in order to meet deadlines; however, the lack of fulfillment is creating stress that is manifesting within her family and impacting her negatively at work. A further demonstration of Maslow’s hierarchy is Susan’s desire to increase the pay for the workers. This may help Susan to fulfill a social need of helping those in her charge, but with the lack of lower-order fulfillment, it has a lower priority. Instead, Susan acknowledges that she must offer pay that is commensurate with the work being performed by her employees. This is Susan’s attempt to fulfill the workers’ safety, esteem, and self-actualization needs. In general, according to Banerjee (1995), Maslow’s theory has merit, but it remains too generalized for practical purposes as people vary greatly in the priorities placed on the higher-order needs.

Herzberg’s hygiene-motivation theory (Banerjee, 1995; Robbins & Judge, 2010), on the other hand, attempts to validate measures to prevent dissatisfaction (hygiene) while promoting a different set of measures designed to increase satisfaction (motivation). Hygiene measures, according to Fred Luthans (as cited in Banerjee, 1995), are “a necessary floor to prevent dissatisfaction and a take-off point for motivation” (p. 80). Herzberg’s theory can be applied to this scenario, also (Laureate Education, n.d.). Susan attempts to mitigate employee dissatisfaction by using hygienic control measures increasing pay. Unfortunately, Susan feels that this might have an adverse effect on current employee morale as there is only enough money to increase the starting pay for new employees. While Susan thinks additional pay would seem to positively impact motivation by increasing job satisfaction, providing raises only to new employees seems contradictory and may only serve to negatively effect hygiene causing dissatisfaction among the ranks of employees. Susan should find other ways to mitigate hygiene factors and promote novel motivational factors. Susan shows low need for power, an elevated need for achievement, and a questionably neutral need for affiliation, in this case (Robbins & Judge, 2010).

People are motivated by a number of factors, both intrinsic and extrinsic, according to Deci’s self-determination theory of motivation (Robbins & Judge, 2010; Ryan & Deci, 2000), and later, Vroom’s expectancy theory (Banerjee, 1995; Robbins & Judge, 2010). In the scenario, there is limited information with which to draw definitive conclusions as to the sincere motivations of Susan. However, based solely on the information provided, Susan appears to be driven mostly by intrinsic factors of self-efficacy. Though it would be difficult to consider that Susan might perform her job without extrinsic reward, it seems that the self-recognition of her ability to earn money for her household is a more satisfying reward than the pay, itself. This might explain why Susan is willing to stay late often and complete her tasks in a timely manner. Also, this might explain her frustration with her administrative assistant: a perceived lack of internal motivation on Grace’s part (Heath, 1999). Further, Susan’s boss is setting a deadline that, although difficult, is obtainable, thereby also demonstrating an effective example of goal-setting theory (Robbins & Judge, 2010).

More important, though, to many people is their sense of justice and equity. Equity theory tells that work put in should equal reward output. In this sense, I worry that Susan will soon suffer fatigue, a lower-order need will avail itself for fulfillment, and Susan will no longer perceive the output as great as the effort. If this occurs, Susan will feel slighted and will lose motivation. Ironically, this is the exact fear she has about her employees who will not receive a raise.

Overall, the scenario plays out just as any day in any office might. Susan is performing the common tasks of a manager, ensuring a smooth and efficient business operation, while trying to remain fair and just to the employees. If Susan has a concrete understanding of the motivational forces within and without her workforce, she would do well to harnessing those.

References

Banerjee, M. (1995). Theories of motivation. Organization behaviour (3rd ed.; pp. 72-108). Retrieved from http://books.google.com/

Heath, C. (1999). On the social psychology of agency relationships: Lay theories of motivation overemphasize extrinsic incentives. Organizational Behavior and Human Decision Processes, 78(1), 25–62. doi:10.1006/obhd.1999.2826

Maslow, A. H. (1943). A theory of human motivation. Psychological Review, 50(4), 370-396. doi:10.1037/h0054346

Robbins, S. P. & Judge, T. A. (2010). Motivation concepts. Essentials of organizational behavior (pp. 62-79). Upper Saddle River, NJ: Pearson Prentice Hall.

Ryan, R. M. & Deci, E. L. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist, 55(1), 68-78. doi:10.1037//0003-066X.55.1.68

Academia, Health Care, Public Health, Society

Determinants of Health – Mental Illness

When attempting to solve many of the issues relevant to public health, it is essential to understand the factors that contribute to disparities across various ethnic, racial, cultural and socioeconomic boundaries (Satcher & Higginbotham, 2008). In northeastern Connecticut, however, health disparities are primarily related to the socioeconomic strata, as much of the population is Caucasian and there are identifiable health disparities within this group (U.S. Census Bureau, 2002, 2008; U.S. Department of Health and Human Services, 2009). The disparity that I will focus on in this paper is mental illness.

According to Adler and Rehkopf (2008), unjust social disparity leads to greater health disparity, but what is unjust about social disparity? Adler and Rehkopf continue to describe efforts of researchers to evaluate how socioeconomic status, both, in conjunction with and independent of race or ethnicity, contribute to health disparities. There exists a significant difference in the manner in which different cultures approach mental health needs (Hatzenbuehler, Keyes, Narrow, Grant, & Hasin, 2008). Whites, who are more prone to suffering mental health issues, according to McGuire and Miranda (2008), preferring to seek professional care while Blacks are more likely to opt for self-directed care. Though Wang, Burglund, and Kessler (2001) tell of mental health treatment disparities between Whites and Blacks, in their study, 14 times more Whites responded than Blacks which may suggest that Whites are more apt to discuss mental health issues and Blacks might not unless they are motivated by extrinsic factors, such as poor care or the impression thereof. As long as Blacks are not prevented or discouraged from seeking care, there is no injustice in choosing self-care; however, it may not be the most effective option. Cultural awareness on the part of health care providers who may have an opportunity to provide health education to Blacks may alone increase the utilization of mental health services among the Black demographic.

More importantly, mental illness often exists in the presence of poverty and the lack of education. Much of the literature, such as Schwartz and Meyer (2010), seems to make the implication that low socioeconomic status is a causative risk-factor for mental illness, yet the literature also makes the distinction that one of the lowest groups on the socioeconomic ladder, Blacks, have a lower incidence, overall, of mental illness. This may be true in some instances; however, it is more likely that mental illness may be the proximal cause for an afflicted person’s socioeconomic status, especially if the illness manifested early enough to interfere with the person’s education.

More research needs to be undertaken to identify effective programs that aim to mitigate bias of mental health conditions within the community. As mental health disorders lose their stigma, more people who suffer from mental health issues will be able to seek care comfortably and unafraid, leading to increased treatment rates and increased synthesis within the community. This synthesis alone would alleviate much of the socioeconomic burden. Additionally, we need to shift our focus and strive to fix health issues locally, not nationally or globally. The world is comprised of a network of communities of individuals. Impacting the individual is the first step to affecting positive social change. Focusing on individual health will ultimately impact community, national, and global health.

The U.S. Health care system is overtaxed in caring for people with mental illness. According to Insel (2008), we need to refocus our efforts on providing care for mental illness to reduce the enormous indirect costs estimated at $193.2-billion per year. A viable solution in addressing mental illness as a health disparity, I feel, lies in understanding the manner that mental illness causes lower socioeconomic status which, in turn, causes risk of disparate care. Programs designed to aim for situational mitigation instead of mental health recovery will be less costly, more effective and, overall, more ideal. There will still be an obvious and great need for treatment and recovery programs, but with mitigation, I posit that they will be more effective, also.

References

Adler, N. E. & Rehkopf, D. H. (2008). U.S. disparities in health: descriptions, causes, and mechanisms. Annual Review of Public Health, 29(1), 235-252. doi:10.1146/annurev.publhealth.29.020907.090852

Hatzenbuehler, M. L., Keyes, K. M., Narrow, W. E., Grant, B. F., & Hasin, D. S. (2008). Racial/ethnic disparities in service utilization for individuals with co-occurring mental health and substance use disorders in the general population. Journal of Clinical Psychology, 69(7), 1112-1121. doi:10.4088/JCP.v69n0711

Insel, T. R. (2008). Assessing the economic costs of serious mental illness. American Journal of Psychiatry, 165, 663-665. doi:10.1176/appi.ajp.2008.08030366

McGuire, T. G. & Miranda, J. (2008). New evidence regarding racial and ethnic disparities in mental health: policy implications. Health Affairs, 27(2), 393-403. doi:10.1377/hlthaff.27.2.393

Newport, F. & Mendes, E. (2009, July 22). About one in six U.S. adults are without health insurance: Highest uninsured rates among Hispanics, the young, and those with low incomes. Gallup-Heathways Well-Being Index. Retrieved from http://www.gallup.com/poll/121820/one-six-adults-without-health-insurance.aspx

Satcher, D. & Higginbotham, E. J. (2008). The public health approach to eliminating health disparities. American Journal of Public Health, 98(3), 400–403. doi:10.2105/AJPH.2007.123919

Schwartz, S. & Meyer, I. H. (2010). Mental health disparities research: The impact of within and between group analyses on tests of social stress hypotheses. Social Science and Medicine, 70, 1111-1118. doi:10.1016/j.socscimed.2009.11.032

U.S. Census Bureau. (2002). Census 2000. Retrieved from http://www.ct.gov/ecd/cwp/view.asp?a=1106&q=250616

U.S. Census Bureau. (2008). Population estimates: Annual estimates of the resident population by age, sex, race, and Hispanic origin for counties in Connecticut: April 1, 2000 to July 1, 2008 [Data]. Retrieved from http://www.census.gov/popest/counties/asrh/files/cc-est2008-alldata-09.csv

U.S. Department of Health and Human Services. (2009). Community health status indicators report. Retrieved from http://communityhealth.hhs.gov/