APPENDIX A: PAPER ABSTRACTS

FOREWORD

SOCIAL AND STRUCTURAL DETERMINANTS OF HEALTH AND HEALTH EQUITY

AUTHORS: JAMES MARKS, MD, MPH, HELENE GAYLE, MD, MPH, AND DWAYNE PROCTOR, PHD

The National Academy of Medicine (NAM) serves as a national leader and advisor on issues relating to the science and practice of medicine, health care, and good health and well-being. This leadership also extends to the arena of health equity and social determinants of health. The NAM’s Culture of Health Program, in partnership with the Robert Wood Johnson Foundation, recently released the consensus study Communities in Action: Pathways to Health Equity, which reviewed the science of inequity and highlighted nine communities taking action to reduce health disparities across the country. The program held its first stakeholder meeting in January 2017, bringing together leaders from a variety of fields, including policy, research, philanthropy, and community organizations, to reflect that interdisciplinary solutions are critical to furthering health equity in the United States.

Inequities in health have existed among humans since our beginnings as a civilization. In the mid-1800s, John Snow’s discovery that cholera deaths were associated with a contaminated water pump in urban London catalyzed the formation of public health as a scientific discipline and cemented the significance of health equity in public health practice. As William Foege, former president of the American Public Health Association, once said, “The philosophy of public health is social justice.” Because discrimination, poverty, and other forms of socioeconomic inequality lead to negative health outcomes in systemic ways, the goal of creating a culture of health must be central to the medical community’s vision of optimal health for all.

Social determinants of health are the myriad ways community characteristics affect health equity, such as demographic factors, income levels, educational institutions, transportation infrastructure, and access to social services. The NAM’s report and meeting repeatedly emphasized the importance of investing in early childhood programs and developing human capital for children; effectively using changing trends in communication and technological advancement to reach wider audiences; infusing health equity into every aspect of community living, from urban planning to economic development; and the importance of data collection in measuring and achieving health outcomes. The NAM’s discussions highlighted the success of multisectoral approaches to better health and well-being, integrating efforts across community governments and institutions in health, education, law enforcement, and other social agencies to achieve collective impact.

Despite our scientific and technological innovation, the United States has been unable to translate these advances into better health outcomes compared to other countries. At this watershed time in our nation’s history, every institution has a part to play in our mission of building a culture of health. The core value of medicine is the application of science to help those in need, and through community-based, multisectoral initiatives, we can live up to this idea and achieve health equity in America.

HEALTH INEQUITIES, SOCIAL DETERMINANTS, AND INTERSECTIONALITY

AUTHOR: NANCY LÓPEZ, PHD, AND VIVIAN L. GADSDEN, EDD

There is growing evidence to suggest that health disparities do not exist in isolation but are part of a reciprocal and complex web of problems associated with inequality and inequity in education, housing, and employment. Problems in health disrupt the human developmental process; they undermine the quality of life and opportunities for children and families, particularly those exposed to vulnerable circumstances. Health prevention and successful interventions depend not simply on the existence of care but also on access to care, quality of care, experience with care, and overall well-being.

A commitment to developing an intersectionality lens can advance health disparities research, practice, and leadership. Intersectionality is an intentional focus on the simultaneity of race/racism, gender/sexism, class/classism, sexual orientation/heterosexism, and physical disability by linking individual, institutional, and structural levels in a given sociohistorical context. The potential power of intersectionality as a transformational paradigm lies in two domains relevant to understanding social determinants. First, it examines closely and raises questions about the meaning and relationship between different social categories. It also pushes against the idea of “blaming the victim”—the simplicity of explaining health or educational outcomes through attributions to individuals’ genetics and social behaviors alone. Second, by focusing on the convergence of experiences in context, it serves as an anchor in advancing social justice aims for all marginalized communities that have experienced and continue to experience structured inequalities.

Research has uncovered several interconnections between health and environmental and social factors but has not always shifted paradigms sufficiently to either disentangle interlocking issues or tease apart the ways social factors and institutional barriers at once interlock to prevent meaningful and sustainable change. Even the most agentive individual who is faced with daily problems of racial, class, gender, or disability discrimination may find fighting against these inequalities daunting. The relationship between oppression and privilege has become so intrinsic to societal practices that those who enact either or both may be unaware of their effects on others.

Intersectionality also acknowledges the ways policies and practices reinscribe positions of power, dominance, and oppression that contribute to the social

determinants of health, education, and well-being. Social determinants are tied to matters of equity—to the availability and distribution of resources and power. These policies and practices are historical factors that reify inequalities, making them appear to be naturally occurring rather than the result of a social system.

An intersectionality lens can address the multiplicity of identities contributing to the social determinants of health for diverse populations of children, youth, and families and to move closer to effecting change.

IDENTIFYING AND IMPLEMENTING OPPORTUNITIES TO REALIZE HEALTH EQUITY THROUGH A LIFESPAN LENS OF LEGAL AND POLICY RESEARCH

AUTHORS: PATRICK H. TOLAN, PHD, VELMA MCBRIDE MURRY, PHD, ANGELA DIAZ, MD, PHD, MPH, AND ROBERT SEIDEL, MLA

The notion that health equity is a fundamental form of justice emanating from basic human rights suggests that health disparities should be central to health research, evaluation, and policy. In order to realize health equity, researchers must take a lifespan perspective and evaluate the policies and regulations that sustain health disparities. There is a need to move beyond the repetitive documentation of the existence of disparities, to a paradigm that illuminates the mechanisms through which health equity can be realized.

Health disparities refer to systematic health differences related to group membership and access to resources that are avoidable or malleable, and are primarily socially determined. The very definition of health disparities proposes that systematic differences between groups can be affected or eliminated because they are representative of social and politically based inequities.

Using a framework where health equity is central when prioritizing a national scientific agenda has the potential to reduce health disparities. Having more detailed information about the actual mechanisms through which disparities in susceptibility to disease are linked to access to resources, treatment quality and availability, and life-course trajectories is critical for recognizing the extent of the inequity. A distinct advantage of the life-course framework in explaining the systematic variations in individual and group health trajectories is that it allows for greater understanding of where equity is being realized or promoted, and where opportunities exist to overcome or undercut inequity promoting influences.

To raise the visibility of health equity as a matter of justice and ensure that all social groups have equal opportunity to reach their full potential as healthy as possible over their lifespan, there is a need to reduce and eliminate systematic differences in the health of groups and communities. The application of the highest-quality research from a lifespan developmental approach in studying outcomes related to health and disease combined with the empirical study and systematic policy analyses of the regulations and laws that affect health equity are essential to reduce health disparities and improve health equity and justice.

THE CHARACTER ASSASSINATION OF BLACK MALES: SOME CONSEQUENCES FOR RESEARCH IN PUBLIC HEALTH

AUTHORS: ALFORD A. YOUNG, JR., PHD

A consequence of pervasive social inequality is the regard by those of higher socioeconomic standing of those at the bottom of American social hierarchies, especially men and boys of color, as unworthy citizens. Many people believe that the poor have brought their condition upon themselves as a consequence of being embedded in moral, cultural, and biological deficiencies. African American males register in the minds of the American public as threatening, hostile, aggressive, unconscientious, and incorrigible. Beliefs about their moral and cultural shortcomings help engineer a warped vision not only of their capacities for positive individual and collective action, but of their very public identities.

Bearing the mark of unworthiness and the accompanying social undesirability that comes from it subjects African American males to an extreme form of character assassination. A character assassination is an act of consistently presenting false or indicting arguments about a person in order to encourage his or her public dislike or mistrust.

For example, black males do not necessarily reject mainstream institutional spheres such as schools but rather have negative experiences with individuals in these spheres. The result is that they face problems with their encounters with schools, employers, and legal authorities such as the police, but not with schooling, employment, or the institution of law in a general sense.

Media coverage of public debates following the deaths of numerous African American males in recent years has centered on two forms of public response and inquiry. One was whether these individuals conducted themselves as proper or deserving people. The other was whether they appeared to be highly threatening or dangerous in the moments prior to their deaths. Implicit in these and other tragic deaths of such males was the notion that what they did, who they were, or how they appeared to be at the time in which they were approached by those who encountered them was credible explanation, if not complete justification, for what transpired.

The health consequences of racism include various forms of trauma which affect the psychological and physiological states of being in these males. The existence of character assassination may not result in any explicit impingement upon individual behavior or conduct. However, the extreme surveillance of and critical social judgement made about the conduct, action, or dispositions exemplified by black males may be causal factors for a range of unhealthy emotional and physical states of being. Ultimately, any wholesale mitigation of the character assassination of these males can only occur if there is a shift in the public imagination of them.

PROMOTING POSITIVE DEVELOPMENT, HEALTH, AND SOCIAL JUSTICE THROUGH DISMANTLING GENETIC DETERMINISM

AUTHORS: RICHARD M. LERNER, PHD

Reductionist, genetic determinist ideas have created inequities in access to individual social resources and opportunities. As a result, these ideas have created inequities in health, education, and social justice. Social justice focuses on social inequities, characterized as avoidable and unjust social structures and policies that limit access to resources based solely on group or individual characteristics such as race/ethnicity, age, gender, sexual orientation, physical or developmental ability status, and/or immigration status, among others. Social justice emphasizes the rights of all groups in society to have fair access to and a voice in policies governing the distribution of resources essential to their physical and psychological well-being.

Modern genetic determinist ideas suggest that genes account for racial differences in wealth and economic institutions and disregard the effects of the social determinants of health (i.e., discrimination, racism, and lack of education). However, human development has the capacity for plasticity, which contradicts the notion that genes preclude individuals from profiting from health or education programs. An alternative to genetic determinism is the relational developmental systems (RDS) metamodel which embraces a new understanding of the role of biology in human development. The RDS metamodel is predicated on an integrative understanding of evolution and epigenetics. The conceptual emphasis in these theories is placed on a mutually influential relationship between individuals and their contexts. Thus biological, psychological, and behavioral attributes of the person, combined with culture, have a temporal (historical) component. For example, the genome of infants can be modified by epigenetic changes involving experiential and environmental variables, and this modification can be transmitted across generations.

Developmental science can be used to accurately reflect the diversity of human development; dismantle modern notions of genetic determinism; and build bridges across various disciplines, professions, and communities to ensure integrative, multidisciplinary, collaborative approaches to promoting human health and social justice.

PHILOSOPHICAL PERSPECTIVES ON SOCIAL JUSTICE: A FRAMEWORK FOR DISCUSSING A CHILDREN, YOUTH, AND FAMILIES HEALTH POLICY AND RESEARCH AGENDA

AUTHORS: ROBERT SEIDEL, MLA, PATRICK H. TOLAN, PHD, ANGELA DIAZ, MD, PHD, MPH, AND VELMA MCBRIDE MURRY, PHD

Discussions on social justice and health equity often assume that stakeholders have universally agreed upon definitions of these two concepts and adhere to a certain set of foundational principles. However, outside of academic circles, the ideas of “social justice” and “health equity” are rarely articulated, and people may have differing views of what these ideas mean and their role in furthering health policy agendas. In the American context, greater clarification of these terms can acknowledge implicit variations in our values and assumptions and better benefit efforts to achieve effective health policy. Various philosophical schools of thought have many definitions of social justice and ideals for how people should interact and how communities should allocate resources. In discussing social justice and health equity, the two major categories of philosophical perspectives are “individual-centric,” which emphasize the rights and well-being of the individual, and “community-centric,” which emphasize the well-being of the community or society.

“Individual-centric” perspectives share similarities with the prevailing American political philosophy of liberalism, a central concern for the protection and enhancement of the freedom of individuals. More specifically, traditional American liberalism seeks to realize the promises of the U.S. Constitution to all people regardless of natural or social differences; this philosophy has been demonstrated in movements to attain civil rights for women, African Americans, and LGBTQ+ people. Libertarianism favors an abundance of choice, personal agency, and a reduction in government regulation over initiatives for equal opportunity, but this perspective also argues that increasing individual choice will lead to greater justice. Rawls’ concept of justice as fairness believes that policies and resources should be targeted toward the reduction of inequities in society. Nussbaum and Sen’s capabilities approach moves past typical conceptions of human rights and posits that differential opportunity is necessary to compensate for inherent disadvantages among people.

“Community-centric” perspectives are associated with the majority of cultures in human history and give primacy to the success of an overall society over the individual. Tribal social organization principles require contributions from all

to a society’s productivity, while ensuring the equal status of every individual in the community. Confucianism proposes that the moral conduct of individuals engenders political order, and that personal identity is defined by a person’s relationships. Buddhism understands the interdependency of people and warns that ignoring the plight of the poor leads to negative effects for all of society. Utilitarianism, based on the idea of maximizing benefits, is problematic in discussing health equity due to differing judgments of the meaning of “good” and the means by which this good can be achieved. Socialism and communism can be seen to some extent in nationalized health insurance systems in Europe and deserve further consideration from the American perspective.

By investigating various philosophical perspectives on social justice more deeply, Americans can prioritize their values regarding individual liberties, government regulation, community interdependency, and resource allocation. This understanding of our values would, in turn, strengthen our debates over the role of social justice and health equity in our society and support the creation of better policies and programs in health care.

EXPULSION AND SUSPENSION IN EARLY EDUCATION AS MATTERS OF SOCIAL JUSTICE AND HEALTH EQUITY

AUTHORS: SHANTEL E. MEEK, PHD, AND WALTER S. GILLIAM, PHD

Social justice—equal access and opportunity for all—has been a core American value since our founding. That value, however, is not fully realized in the lives of millions of Americans, nor has it ever been. Scientists have a central role in addressing the challenges that face society. A primary purpose of research should be to inform the policies and practices that in turn address serious problems in our country and around the world. Racial, ethnic, socioeconomic, and ability-based disparities and inequities are widespread across most aspects of society. These disparities start early, perhaps before birth, and are pervasive throughout children’s lives before they even enter kindergarten.

It is well established that the beginning years of any child’s life are critical for building the early foundation needed for success in school and later in life. During this period, the brain develops at a pace unlike any other, and is extraordinarily sensitive to and affected by children’s environments, experiences, and relationships. Early adversities can have lasting consequences—and these adversities (and the protective buffers) are inequitably distributed.

Low-income children and children of color alike have less access to high-quality early learning programs. Young boys of color are especially more likely to be pushed out of early childhood programs through exclusionary practices like suspension and expulsion. While African American children make up 18 percent of preschool enrollment, they make up 48 percent of preschoolers suspended. Early expulsion and suspension predict later expulsion and suspension, and students who are expelled or suspended are as much as 10 times more likely to drop out of high school, experience academic failure and grade retention, hold negative school attitudes, and face incarceration than those who are not. Expulsion and suspension are pivotal points of influence in young children’s lives that may contribute to entry into the “prison pipeline” and therefore must be immediately addressed by a broad coalition of stakeholders, including researchers; policy makers; and local districts, schools, and community-based programs.

Understanding the degree to which implicit biases may contribute to expulsion and suspension decisions by early educators and administrators is an important step to a fuller understanding of the source of disciplinary disparities. No

intervention to date has targeted, examined, and published findings on reducing or eliminating the racial disparities noted in expulsion and suspension data in early childhood settings, which is a clear and pressing need.

LESSONS FOR HEALTH EQUITY: MILITARY MEDICINE AS A WINDOW TO UNIVERSAL HEALTH INSURANCE

AUTHORS: JEFF HUTCHINSON, MD, FAAP, RAQUEL MACK, MS, TRACEY PÉREZ KOEHLMOOS, PHD, MHA, AND PATRICK H. DELEON, PHD, MPH, JD

Health disparities result from multifaceted variables including access to health care, and discrimination associated with socioeconomic status, education, social support, insurance, race, ethnicity, and gender. The purpose of this paper is to identify lessons learned and future research opportunities from the two national health systems that model universal health care, the Military Health System (MHS), and the Department of Veterans Affairs (VA).

The federal health care system provides an excellent vehicle for objectively exploring the underlying determinants of health disparities. The Military Health System primarily serves the active duty population, their family members as well as some retirees, whereas the VA exclusively treats veterans—a generally older cohort. The differences in health outcomes are influenced by the different patient populations, organization structure, and priority. The similarities in disparities that have decreased are most likely the result of electronic medical record use, similar provider cohorts, and a single insurer. Increased focus on these health care delivery systems has the potential to clarify sources and solutions to health disparities.

The data available from the VA and MHS demonstrate both elimination of disparities and areas where disparities continue despite equal access and resources. Cultural factors of disparities arise from gender, religion, race, ethnicity, and any shared group experience. Theoretically, the traditional barriers of access, patient and provider economic concerns, and provider shortages should explain disparate outcomes. Race-based, cultural distrust of military medicine is not eliminated immediately upon entering the service. Ongoing research indicates a lack of disparities across a variety of health and surgical-related access and outcomes including maternal, cancer, and heart surgical procedures. However, several biases remain in place even after universal coverage eliminates access and resource discrepancies. Other areas that continue to demonstrate disparities require exploration of new variables that contribute to health disparities (such as rank and service) to improve military and veteran health care.

PRINCIPLES OF ADOLESCENT- AND YOUNG-ADULT-FRIENDLY CARE: CONTRIBUTIONS TO REDUCING HEALTH DISPARITIES AND INCREASING HEALTH EQUITY

AUTHORS: ANGELA DIAZ, MD, PHD, MPH, AND KEN PEAKE, DSW

The behavioral patterns that evolve during adolescence help determine young people’s immediate health status and influence their long-term health, including their risk for developing chronic diseases in adulthood, and which can result in health disparities further down the road. During adolescence, the responsibility to be healthy begins to shift from caregivers to young people, making it critical to ensure that young people have access to health care, education, and the opportunity to develop the skills they need to be productive and make valuable societal contributions. Many young people lack health literacy and have no experience navigating the silos by which health care is organized. Health care providers can play a unique role in providing appropriate interventions that encourage young people to become great health care consumers and adopt healthy behaviors.

Despite the opportunity that adolescence presents for health care systems to shape future well-being, the current health care delivery system is not sufficient in addressing the needs of young people. Historically adolescents have long received less health care than other age groups, even after the implementation of the Affordable Care Act. A key challenge that will shape adolescent health in the next decade is presented by the fact that the adolescent population is becoming more ethnically diverse. The growing diversity of young people involved in the health care system will demand cultural responsiveness if health care needs are to be properly met.

In recognition of the unique developmental characteristics, concerns, opportunities for health promotion and vulnerabilities of adolescents, along with their relative inexperience in seeking or navigating health care independently, there is an emerging consensus about the principles that should guide the design and delivery of adolescent health services. These principles include equitable care; reaching out to those most vulnerable; accessible and easily navigated care; integrated services; confidential care; informed consent; developmentally appropriate care; relationship-based care; supporting one-on-one youth provider interactions; sensitive, trained, and reflective staff; creating a safe space that is nonjudgmental; respectful care; culturally competent care; and promoting parent-child communication. These principles can be used in adolescent- and young-adult-specific health centers to understand and mitigate disparities related to lack of access, poor quality of services, or services that are inadequate.

STORIES ABOUT BLACK MEN IN THE MEDIA AND THEIR CONSEQUENCES FOR HEALTH

AUTHORS: KAREN E. DILL-SHACKLEFORD, PHD, SRIVIDYA RAMASUBRAMANIAN, PHD, MA, AND LAWRENCE M. DRAKE II, PHD, MA, MPA

At this particular juncture in U.S. history, the fictional entertainment and news media stories we tell about black men are vitally important to our individual and collective development as a society. Despite the progress of black males in education, industry, and other areas of America’s landscape, the media continues to highlight a negative narrative that associates black men with violence, crime, and poverty. In the media, black men are overrepresented as street criminals and underrepresented in positive social roles and in positions of power. A number of studies have demonstrated that the stories we tell about black men in the media have negative consequences such as increased prejudice and decreased support for pro-black ideas and policies.

News reports often use subtle cues and visual codes that rationalize white superiority and present black men as disruptive and troublesome. Research documents that news stories about black men often attribute their failures to personal deficiencies such as incompetence or lack of motivation, rather than to systemic factors such as discrimination or lack of access to quality education, employment, and health care. Simply bringing to mind a stereotype or counter-stereotype is sufficient to influence subsequent judgments, beliefs, and behavioral intentions.

Apart from encouraging diverse and positive portrayals of black men in mainstream media, it is important to foster alternative media spaces for black voices to be amplified and heard. The Black Lives Matter (BLM) movement began after a series of events involving mistreatment, mishandling, or violence toward African Americans by white police officers and their authorities. The BLM movement offers a perspective on how to plot the use of technology-based communication platforms to expose the injustice of the violence being perpetrated while unifying their message.

A growing number of researchers have argued that pervasive racism, including race-laced messages fostered by the media, has an adverse impact on the health conditions of blacks and other racial minorities. The stigmatization of black men extends to the health domain because prejudice and discrimination have been shown to elevate depression and anxiety, with cascading effects on numerous chronic illnesses. The factors are often characterized as social determinants of health and contribute to racial health disparities. When we tell false stories about

an entire demographic, we cause stress and ill health and even aggression in not only that demographic, but in others who encounter them.

It is important to become aware of the detrimental ways media stories shape our idea about the world and ourselves. Efforts to intervene can occur through media literacy education to educate the public to become informed media consumers. Most research studies on media effects generally focus on majority participants and the segments of our population who enjoy more privilege. Therefore, more research is needed that gives voice to minority participants. It is imperative that we find space in our schools to educate our children in media literacy. This would allow for dialogue about responsibility for messaging and for responding to messaging that is derogatory to any one race.

History has made it abundantly clear that shared cultural stereotypes of black men are contributing to brutality and injustice towards black men. Popular media have been part of the problem in perpetuating negative race-related messages, forestalling resolutions to racial tensions in our society. As we look for opportunities for positive change, there is evidence to suggest that including popular media in the solution is a viable option.

CHALLENGES AND PROMISE OF HEALTH EQUITY FOR NATIVE HAWAIIANS

AUTHORS: NOREEN MOKUAU, DSW, PATRICK H. DELEON, PHD, MPH, JD, JOSEPH KEAWE‘AIMOKU KAHOLOKULA, PHD, SADÉ SOARES, JOANN U. TSARK, MPH, AND COTI-LYNNE PUAMANA HAIA, JD

Health equity, the attainment of the highest level of health for all people, is yet to be realized for many populations in the United States. Health equity focuses on diseases and health care services, but is also broadly linked to social determinants, such as socioeconomic status, the physical environment, discrimination, and legislative policies. For Native Hawaiians, the indigenous people of Hawai’i, the elusiveness of health equity is reflected in the excess burden of health and social disparities.

Native Hawaiians make up approximately 21 percent of the state’s multiethnic population of 1.4 million. The cumulative impact of the colonization, oppression, and cultural suppression of Native Hawaiians during the 19th and 20th centuries has subjugated them to long-term injustice and discrimination. The historical loss of population, land, culture, and self-identity has shaped the economic and psychosocial landscape of Hawai’i’s people, and limits their ability to actualize optimal health.

Consequently, Native Hawaiians have the shortest life expectancy and exhibit higher mortality rates than the total population due to heart disease, cancer, stroke, and diabetes. Poor health is inextricably linked to socioeconomic factors, and Native Hawaiians are more likely to live below the poverty level, experience higher rates of unemployment, live in crowded and impoverished conditions, and experience imprisonment.

Native Hawaiians’ cultural values and beliefs are organized around the collective relationships of the family, community, land, and spiritual realm. Therefore, effective interventions will incorporate these beliefs. There are various model programs that have the potential to impact health through policies that increase the Native Hawaiian workforce in health care; tailor research to specifically examine and treat health disparities among Native Hawaiians; and develop new clinical interventions that are community-based and culturally anchored.

For Native Hawaiians to eventually achieve health equity there must be (1) an institutional commitment by universities to train a sufficient number of Native Hawaiians in all disciplines to address health disparities and create health solutions; (2) the establishment of culturally sensitive health care systems which will affirmatively seek out Native Hawaiian patients; and (3) a serious appreciation for the complexity of Native Hawaiian culture at the policy level.

FETAL ALCOHOL SPECTRUM DISORDERS IN AFRICAN AMERICAN COMMUNITIES: CONTINUING THE QUEST FOR PREVENTION

AUTHOR: CARL C. BELL, MD

Over the past decade, public health research has placed an increasing emphasis on prevention. However, a major piece of the dialogue has been overlooked: fetal alcohol exposure (FAE). Several diagnoses fall under the category of fetal alcohol spectrum disorders (FASD)—the overarching diagnosis that is caused by FAE. Thanks to public health efforts by the Centers for Disease Control and Prevention, National Institute on Alcohol Abuse and Alcoholism, and Substance Abuse and Mental Health Services Administration, the knowledge that women should not drink during pregnancy is nearly ubiquitous. Unfortunately, a large proportion of women are drinking socially before they realize they are pregnant. This is further supported by the fact that nearly 50 percent of pregnancies are unplanned. Additionally, women 18–24 years old, who are poor, have unintended pregnancy rates 2–3 times higher than the national average. The consequence of alcohol consumption during pregnancy is birthing a child with fetal alcohol spectrum. There is a higher likelihood of FASD cases in African American communities, partly due to the increased access to alcohol because of the overabundance of liquor stores in the African American community.

Numerous disorders have been associate with FASD, exhibited in varying degrees of impaired growth, including cognitive and behavioral abnormalities and facial abnormalities. Future problems may include learning disabilities; school performance deficits; inadequate impulse control; social perceptual problems; language dysfunction; abstraction difficulties; mathematics deficiencies; and judgment, memory, and attention problems.

FASD produces an acquired biological disability of subtle brain damage. This subtle brain damage masquerades as a whole host of educational, criminal, and psychiatric disorders. These children’s adversities are further exacerbated, as many of them are also victimized and/or exposed to violence at a young age. The combination of biological and environmental risk is often viewed as the central factor that places youth at risk for numerous disparities. For example, given the likelihood of dysregulatory behaviors among FASD children, it is highly probable that their behavior may be misdiagnosed, setting them up for early entry into the juvenile justice system. Although the intellectual and behavioral symptoms of FASD have been attributed to culture in African Americans, the reality is that these behaviors are caused by the social determinants of health that put them at risk for subtle brain damage.

While medical students, historically, have been taught to look for fetal alcohol facies in infants, that the problem has long-term effects over a child’s life course suggests the need to shift to a paradigm. For example, the American Psychiatric Association has included a diagnosis of neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE) in DSM-5. It is possible that the most common problems occurring in all youth—1) speech and language disorders, 2) specific learning disorders, 3) ADHD, and 4) mild intellectual deficiency originated with FASD. FASD awareness is hampered by the lack of understanding that efforts can be undertaken to intervene. Results from animal studies have demonstrated that a choline supplement during pregnancy and postnatally can reduce the damage done to fetuses that have been exposed to alcohol, but human clinical trials have been lagging behind. Despite all the progress in public health, there is an urgent need to bring to the forefront the consequences for children born to mothers who use alcohol during pregnancy.

URGENT DISPATCH: CALLING ON LEADERSHIP TO RESPOND TO VIOLENCE IN BLACK NEIGHBORHOODS AS A PUBLIC HEALTH CRISIS

AUTHORS: SHARON TOOMER AND RAQUEL MACK, MS

People in black neighborhoods across the nation are plagued with unceasing and prolonged violence. There is a failure to target and respond to this public health crisis and social and health injustice. Numerous women, men, girls, and boys are left to navigate the long-term psychosocial effects of continued violence. Violence in black neighborhoods is a public health crisis that requires immediate, decisive, targeted, and swift action involving all sectors in a position to respond with expertise, leadership, and resources.

Community violence is defined as exposure to intentional acts of interpersonal violence committed in public areas by individuals who are not intimately related to the victim. Living under a stagnant cloud of community violence is traumatizing and the immediate and long-term impact of community violence is recognizable. Community violence has a strong impact on the mental health outcomes of children and adolescents. Exposure to violent death causes psychological trauma and can result in complicated grief disorder, which involves extreme immobilization, pronounced psychotic ideation and severe symptoms that persist over a long passage of time. This can also cause a breakdown in psychological functioning. Being in a state of shock, experiencing denial, avoidance or loss reminders, and dysfunctional or health-compromising behaviors are indicators of complicated grief. Consequently, black people are at a greater risk of developing complicated grief disorder because they experience homicide more frequently than the majority population and have elevated grief symptoms in comparison. The effects of trauma are also generational, which supports the case that an immediate and targeted public health response to violence is essential to the well-being and progress of those affected.

Undeniably the United States is a violent nation and violence does not discriminate based on socioeconomic status, race, or ethnicity. But the especially chilling rate and frequency of violence happening in black neighborhoods, and the unaddressed trauma that follow, is discriminate. Until there is the political and societal will to comprehensively analyze, examine, address, and, more urgently, remedy the factors leading to the present-day conditions, violence will continue to plague black neighborhoods across the nation.

So far, law enforcement, the criminal justice system and more punitive measures through legislation (e.g., gun laws) have been the driving solution. But those systems and measures have not curbed the violence and they do not address the emotional and mental health needs of traumatized people in black neighborhoods. The essential and immediate need is a declared public health crisis followed by targeted, multifaceted action and resources.