Get a Flu Shot!

It seems like everywhere I go right now, people are talking about the flu. There are definitely years where it seems like it takes out more people than others, but it does actually seem to be pretty bad this year. Regarding flu deaths this year, the CDC says:

The proportion of deaths attributed to pneumonia and influenza (P&I) was 6.7% for the week ending December 16, 2017 (week 50). This percentage is below the epidemic threshold of 6.9% for week 50 in the National Center for Health Statistics (NCHS) Mortality Surveillance System.

A 0.2 difference between the actual proportion of deaths and the epidemic threshold seems pretty small.

Even if you never get the flu and feel like the 15 minutes of hanging around at Walgreens is a waste of time, your immunocompromised friends, family, coworkers, and public transportation sharers will appreciate your having a shot.

Evidence is a Downer – But We Need It

In a season 6 episode of Parks and Recreation, City Councilwoman Leslie Knope decides to champion adding fluoride to the drinking water to prevent endemic cavities. Leslie, in her usual way, provides ample evidence in large binders supporting her position and expects everyone to join her side. However, her rival on City Council, a corrupt dentist, starts sowing uncertainty in the fluoride plan. He goes on a local news show and calls it a dangerous chemical, and when that doesn’t work to sway opinion, recruits the local candy company, Sweetums, to take over the city water system and replace the water supply with basically… gatorade.

What’s Leslie to do? Arguing against the sugary tap water is nearly futile because no one wants to listen to the evidence-based science she has supporting fluoride-treated water. In the end, Leslie reads the ingredients of the sugar-water to the town in a monotone, while her co-worker, Tom Haverford, introduces a re-branded fluoride as T-Dazzle, “which makes your teeth stronger and … starts a party in your mouth.” Constituents swayed to the newly-sexy fluoride and against the newly-boring sugar-water, Leslie wins.

So what does this have to do with public health?

Well, evidence is not so sexy in the real-world, either. Often the people who are tasked with creating laws about health (politicians) are not experts on health and ill-equipped to understand research about best practices in health policy.

A study on barriers and facilitators to use of evidence-backed research for policymakers found that many policymakers, particularly state politicians who are part-time, have little time and few resources to actual research issues that they’re making laws about. On top of that, many were unable to critically analyze research and tell what sources were reliable or not. One particular quote that hurt me to read was:

One official observed that in assessing the effectiveness of a new medical procedure, “I just did exactly what…everyone…is hoping I’m not. I talked to my brother-in-law and I Googled it” (Jewell & Bero, 2008, p. 184). (Emphasis mine.)

This is really bad for the rest of us – who have to live with hasty and ill-informed decisions made by politicians! In health sciences, evidence-based medicine is when specific decisions about the best available evidence are made to influence decisions for patients. Research is being done all the time to find out what the best types of therapy are for certain populations, or what screenings should be done for certain types of cancer, or what helps people stick to a diet or exercise plan. This information is useful, but can sit on a shelf unless medical professionals adopt it and communicate it to their patients, and in the legal realm, if policymakers don’t care to understand the latest and best available information, they’re not able to make informed decisions on what kind of legislation is going to bring the most benefit.

Making evidence easy to understand and accessible is important. We probably don’t have to go to T-Dazzle lengths to communicate benefit, but taking into consideration confirmation bias and general antipathy toward evidence and preference toward the familiar is important for making your case. As most people who have had arguments with a political opposite have experienced, throwing facts at someone usually does little to change their mind. We need evidence, but we need to push for better ways to communicate it so it can reach the people who need to hear it.

Pop Public Health: “The Pill”

Country legend Loretta Lynn married at 15 and had 4 children before age 20. (And a few years later had twins!) Her musical success in the 1950s and 60s was a triumph for women, who had few country icons. Many of Lynn’s most successful songs discussed her family life, motherhood, and being a real country woman. “The Pill,” recorded in 1972 and released in 1975, blasted conversation about birth control in rural communities into the mainstream.

Oral contraceptives, known as “The Pill” have not been available for that long. The 1965 Supreme Court case, Griswold v. Connecticut, decided that married couples had a right to use the pill to prevent contraception and Eisenstadt v. Baird decided that single people had a right to use the pill in 1972.

In ‘The Pill,” Lynn proudly sings in the chorus: “This old maternity dress I’ve got / Is goin’ in the garbage / The clothes I’m wearin’ from now on / Won’t take up so much yardage / Miniskirts, hot pants and a few little fancy frills /Yeah I’m makin’ up for all those years /Since I’ve got the pill.” In total, she sings that she’s “got the pill” 7 times in a song that’s just about two and a half minutes.

When Lynn’s label released “The Pill” in 1975, it immediately caused controversy and many country radio stations refused to play it. A 1975 People magazine article noted:

From his pulpit, a preacher in West Liberty, Ky. recently denounced country singer Loretta Lynn and her new song The Pill. The effect was to send much of the congregation scurrying out to buy the record. More than 60 radio stations from Boston to Tulsa have banned the song, but through word of mouth and the FM underground The Pill is selling 15,000 copies a week. For Loretta Lynn, the most honored woman in country music, it is her biggest hit ever.

Lynn’s response to critics of her song was as frank and cavalier as the lyrics: “If I’d had the pill back when I was havin’ babies I’d have taken ’em like popcorn. The pill is good for people. I wouldn’t trade my kids for anyone’s. But I wouldn’t necessarily have had six and I sure would have spaced ’em better.

Lynn later stated in an interview with Playgirl that she’d spoken with several rural doctors who told her that “The Pill” had been especially helpful in communicating the benefits of oral contraceptives to women in rural communities.

Mainstream acceptance of contraception was and is still a huge issue for people of reproductive age. Just last week, The Trump administration “moved to expand the rights of employers to deny women insurance coverage for contraception.” The 55 million women who had the right to copay-free birth control are now at risk of employers using personal religious beliefs to deny access to contraceptives. Without insurance, birth control pills can cost $50 per month, a birth control implant can cost up to $800, and intrauterine devices can cost up to $1000. Certainly all of these are less expensive than pregnancy, giving birth, or raising a child, but the cost of preventing pregnancy can be significant enough that women may not be able to afford reliable methods of contraceptives.

Sexually active people of all ages, religions, and race are all very likely to use or have used contraceptive methods to prevent unintended pregnancy. It’s unfortunate that the current political administration is attempting to curtail access to reliable and safe contraceptive methods. (Call your senator!!) It seems like, in 2017, we could also use a few new popular songs about birth control, right?

A Prescribed Epidemic

Prescription opioids (aka painkillers) like morphine, OxyContin, Percocet, and Vicodin (to name just a few) peaked in 2012, with 81.3 prescriptions per 100 persons. The rate of prescriptions has since fallen, but the United States still represents 80% of world opioid prescriptions (via 2015 data), and has high rates of opioid prescriptions among people under the age of 65 (i.e. the population that is younger and should be healthier). This problem of prescription is deeply embedded in how the United States (fails to) regulate the pharmaceutical industry:

Unlike most of the developed world, the United States puts minimal constraints on aggressive marketing by pharmaceutical companies, whether the target is patients, prescribers, or medical and scientific societies. U.S. pharmaceutical manufacturers have been highly successful at promoting prescription opioids in this lightly regulated, profit-driven health-care environment.

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Opioid abuse is rampant, and is frequently cited as one of the “gateway” drugs to heroin . Opioids are highly addictive drugs because they target parts of the brain that are susceptible to feeling pleasure. Since opioids are more intense than the natural endorphins that humans produce, users of pharmaceutical opioids or illegal opioid drugs (like heroin) feel pulled to chase the high, continue using opioids (and use in increasing amounts), and may become addicted.

Prescriptions for opioids have fallen since an all-time high in 2012, but are still above CDC recommendations. Additionally, length of prescription was found to have actually increased between 2006 and 2015, meaning patients are exposed to the affects of prescription opioids for longer periods, against CDC recommendations. Prescriptions are also doled out unevenly, and a CDC report found that  “the places with the largest number of prescriptions filled tended to have more white residents and higher rates of poverty and unemployment…” See the maps below. On left, rates of opioid prescriptions by state in 2012, on the right, poverty rate by state in 2013. States with higher rates of poverty also have higher rates of opioid prescription.

Just about this time last year, Last Week Tonight did a segment on opioid prescriptions that highlighted the role of aggressive marketing from pharmaceutical companies to influence doctors’ prescriptions of opioid painkillers. [Note: There are some things I find grating in the format of Last Week Tonight but I think this does really quality work at communicating the history of opioid marketing and prescription in the US.] In sum – big pharma played fast and loose with marketing, many doctors fell for it, and now we have huge rates of opioid abuse.

It takes time to change trends in medical practices. It took time for the prescription rates to reach the 2012 highs! So it tracks that it’s going to take some time, even with increased surveillance, research, and awareness before doctors really change opinions about what pain management strategies should look like.

Most articles that I see in local news focus on the opioid epidemic in population health – through interviews with people affected by the opioid crisis and investigations into the areas where opioid addiction is most prevalent. I think many of these articles are great, but they do obscure the macro-level issue of how opioids have come to saturate the medical industry. Fortunately, now more attention is being paid to the source: big pharma. 

41 States of Investigate Pharmaceutical Companies over Opioids (9.19.17 via NPR) – A coalition of state attorneys general have come together to investigate potential impropriety in pharmaceutical companies’ role in the opioid crisis.

“Our subpoenas and letters seek to uncover whether or not there was deception involved, if manufacturers misled doctors and patients about the efficacy and addictive power of these drugs,” New York Attorney General Eric Schneiderman said during his press conference announcing the investigation. “We will examine their marketing practices both to the medical community and the public.”

Are Pharmaceutical Companies to Blame for the Opioid Epidemic? (7.2.17 via The Atlantic) – “Big Tobacco” faced lawsuits in the pursuit of improved public health and has been required to make changes – this article examines the legal possibility of states attorneys general pursuing these cases.

With the tobacco-industry lawsuits, customers were using the product as instructed and got sick. With opioids it’s a different story: Customers are not using the pills as directed, and so it is harder to blame the pharmaceutical companies for the effects of that misuse, according to Lars Noah, a professor of law at the University of Florida. In addition, doctors, not consumers, were the ones targeted by the aggressive marketing campaigns undertaken by pharmaceutical companies, so it can be difficult to link consumer deaths with aggressive marketing.

Whether suits against pharmaceutical companies will be successful is to be determined – already cities and states that have been hit hard by the opioid crisis have taken steps to sue pharmaceutical companies, and it’s possible that in the next year or so we could see court decisions go one way or another. I’m definitely interested to see what happens — but hopeful that this increased attention on the issue of opioid prescriptions will ultimately result in better treatment for those facing addiction and helpful changes made in medical care to prevent exacerbating an already unfortunate epidemic.


Health in a Natural Disaster – How to Help Puerto Rico

Hurricanes Harvey, Irma, and Maria have come and gone, but the destruction of these gigantic weather events remain and will remain through the visible infrastructure damage and the threats to human health.

Breaches at water treatment plants and flooded toxic waste sites in Houston pose hazards to people cleaning up and rebuilding their homes. Water-damaged structures are likely to grow mold, hospitals and medical professionals face closures or running out of resources for those in need of care.

In Puerto Rico, where the electrical grid was nearly wiped out from Hurricane Maria, hospitals are relying on gas-powered generators.  I think it’s really hard, particularly in the areas of US unaffected by these large storms, to imagine the wide-scale damage that has been done. We are very disconnected from the mechanisms that make life comfortable and in some cases, possible. Electricity is something I really rarely think about, same with gas lines, access to fuel, water and food. Cutting off any one of these things would make life more difficult, but dealing nearly all of those things being cut off or made extremely inaccessible that on top of needing specialized medical care (anything from refilling prescriptions, to receiving chemotherapy, to access to a doctor to check out a persistent cough) and needing to rebuild or find a new home are extremely overwhelming. Puerto Rico is facing months of rebuilding efforts to

If you have the means to do so, I encourage you to donate to relief efforts in Puerto Rico. Despite being a US Territory, they are really not receiving enough aid to respond to the magnitude of damage that was done. The longer Puerto Rico goes without an adequate response to Hurricane Maria (and Irma) – the more dire the health of its residents will become.

Money is particularly useful. In-kind items, unless specifically asked for, need to be sorted, inspected, transported and ultimately may be trashed if not useful (clothing donations frequently end up being on the garbage end of donations). If you can donate money, these are some organizations that are doing direct work in Puerto Rico that are particularly focused on health:


What is Reproductive Coercion?

Reproductive Coercion is getting some surprise attention this week after actors Nikki Reed and Ian Somerhalder went on Dr Berlin’s Informed Pregnancy Podcast and related their pregnancy story with a few red flags. (Note: Dr. Berlin is a prenatal chiropractor, chiropractors are not medical doctors.)

I’ve linked the podcast so you can listen for yourself (the section in question is within the first 8 minutes) as well as a Jezebel article that includes a partial transcript, but basically, Reed says Somerhalder knew way before she did that he definitely wanted children, after they were married Somerhalder wanted to have children around the same time his best friends’ did, and then one night on vacation with aforementioned best friends, he popped Reeds’ birth control pills out one by one into the toilet while their friends filmed it and Reed was “freaking out.” Somerhalder ends the story by admitting really he was the one who decided to get pregnant, rather than his earlier use of “we.”

Is this reproductive coercion? And what is reproductive coercion anyway?

Reproductive Coercion (RC) is a type of intimate partner violence where one partner seeks to limit or control the other partner’s ability to make choices about their reproductive health. RC is a spectrum of behaviors, which can range from pregnancy promoting behaviors like tampering with birth control, sexual assault, and preventing someone from seeking an abortion if they want one, to behaviors that attempt to pressure, control, or harm a pregnant person with the aim of ending the pregnancy against their will.

When you listen to the actual audio, it seems as if they’re trying to make this into a cute, jokey story, but I can’t shake the red-flag-feeling. Reed’s response on twitter, shortly after media outlets started picking up on the story on Friday, characterizes the controversy as something the media has blown out of proportion, while most fan replies to her tweets are encouraging and insist that they knew it was lighthearted.

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Here’s the thing – the narrative was their own. There are many times that a controversy over how something was reported in a profile of a celebrity – which come from much longer interviews that are condensed for publication and may only feature select quotes, but this came from a podcast where Reed and Somerhalder were speaking openly and unedited. The multiple journalists and outlets that picked up on the podcast (a podcast which I imagine rarely makes national headlines) raised the red flag over Somerhalder’s description of tossing her birth control in the toilet while Reed was upset, and that Reed asks about the video that was taken and wonders if she was too drunk to remember. These elements are alarming facts, and I when I listened to the actual audio the way they were told didn’t make me feel any better. Maybe they didn’t tell the story in an artful way, but these are tactics that are part of the spectrum of behaviors known as RC.

Reed and Somerhalder later put out a joint statement addressing the allegations of reproductive coercion:

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Celebrities are very often not experts on the topics they become associated with. This is true. However, it is a rare moment in pop culture that a relatively little-known public health problem is gaining some attention, which is ultimately a good place to start a conversation.

Mapping Abortion Access

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This visual representation of abortion access in the USA from The Pudding is really fantastic and informative –albeit depressing.

Since 1973, abortion has been legal (up to the third trimester of pregnancy) following the Supreme Court decision in Roe v. Wade that asserted that pregnancy termination is part of a pregnant person’s right to privacy. Prior to Roe v. Wade, death due to unsafe, illegal abortion accounted for a significant percentage of maternal deaths. Access to safe and legal abortion dramatically reduced maternal deaths and abortion is now one of the safest surgical procedures (safer than giving birth!)

The maps that The Pudding put together (a site I’d never heard of before but I love “visual essays” so goodbye to all of my free time) are really great because they help visualize the specific barriers that people seeking abortion face both in clinic location (the above screenshot) and availability of services according to location and gestation (below screenshot).

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Abortion is legal, but what is legality without access?

In the spring semester, I worked on a group project for a class about abortion access in Pennsylvania, and we plotted clinics that offer abortion services on a map. It becomes abundantly clear, when looking at the map, that the 20 or so providers are clustered in mainly urban areas. But people live in those in-between areas too! Population density is greater in those urban areas, but when you look at 2010 Census data, you can see that there are huge areas of the state where physical access is severely restricted. And these plots don’t even get into the specific restrictions each clinic may have on what types of services they offer.

As The Pudding explains, TRAP (Targeted Regulations of Abortion Providers) laws frequently limit access to abortion by instituting arbitrary rules for “safety,” but are actually medically unnecessary, political moves. It is expensive and time consuming to fight them. (If you’re interested in this – I recommend watching the documentary Trapped.)

Abortion access is an issue I care about a lot, but I think it’s really important to have these kinds of visual representations of data and access because it can succinctly and clearly translate these complicated issues. So check out the maps that The Pudding put together

Climate Change, Hurricanes, and Humans

This Vox video is a really helpful primer on the impact of climate change on weather events. On top of that, Houston is located in a wetland area that has largely been paved over in the last few years, decreasing drainage opportunities. Where water might go naturally into the ground, it’s now sitting on top of tar and the city has filled up like a bathtub.

People are suffering in Houston because of climate change. It is stressful and difficult to deal with homes that have been destroyed, on top of physical risks to health like increased diseases, insects, and injuries.

If you’re looking for places to donate, I urge you to think more locally than large, national relief organizations . Here are links to some people and organizations that will really benefit from any donation, small or large.


Links Roundup: The Wellness Industry

Maybe I’m the target demo, but wellness seems pretty inescapable right now.

In the context of the “wellness industry” that is primarily marketed toward women, wellness is not just personal health but also a kind of moral superiority. The idea of wellness that is sold by Goop, fitness influencers and celebrity chefs on Instagram is a hard nut to crack because truly, people are ill, our modern diets and lifestyles make feeling healthy and maintaining good health difficult, and striving to attain better health is something that all people should be interested in, but it’s also very aesthetically rigid, expensive, and scientifically ambiguous.

Health trends change over time (running used to be weird!), and the wellness industry that promotes everything from “clean eating,” jade vagina eggs, crystals, natural deodorant, exercise regimens, supplements, fasting, and juices (and more!) is diverse and also runs a spectrum of helpfulness.

However, like all trends, I think we should be critical of what we’re consuming (literally and figuratively) and take a step back to examine what exactly we’re being sold. I do partake in some of these kind of crunchy, wellness related fads and enjoy them (chlorophyl water is pretty refreshing, although I don’t think it had any particular impact on my wellbeing), but I try to take everything with a grain of salt. It’s hard to be a woman in the world and not know someone with some kind of disordered eating, and I admit that when I see food bloggers using words like glow, warming, and nourishing about recipes I feel kind of the same way some people do when they hear the word moist. There’s is nothing inherently wrong with it, it just feels like something’s not quite right.

I think the part of these trendy, wellnessy-marketed things that troubles me the most is the idea (sometimes overt, sometimes implied) that attaining whatever your chosen leader’s form of wellness is something that can put you on a path to self-actualization or moral superiority. I think many people can feel empowered by feeling more in control of their health and lives, but kind of how many people who aim to lose a lot of weight and do but don’t become the happy carefree people they assumed they would be when they finally reached their goal weight, there are no magic fixes to what ails you and believing there are is a slippery slope to disappointment.

Anyway, I have a lot of ambivalent feelings about wellness, but I think these articles are all really helpful for understanding the salience of this industry and what we as consumers should consider:

Why we fell for clean eating (8.11.17 via the Guardian) Really comprehensive history of the evolution of “clean eating” and the wellness industry.

You can’t found a new faith system with the words “I am publishing a very good vegetarian cookbook”. For this, you need something stronger. You need the assurance of make-believe, whispered sweetly. Grind this cauliflower into tiny pieces and you can make a special kind of no-carb rice! Avoid all sugar and your skin will shimmer! Among other things, clean eating confirms how vulnerable and lost millions of us feel about diet – which really means how lost we feel about our own bodies. We are so unmoored that we will put our faith in any master who promises us that we, too, can become pure and good.

We exercised with Nina Dobrev and the experience nearly killed us (7.20.17 via Jezebel) For a lighter take on the hegemonic aesthetics of wellness, I really enjoyed this.

Women are flocking to wellness because modern medicine still doesn’t take them seriously (6.15.17 via Quartz) I liked this article because it is more validating of seeking “wellness” than most articles (there are legitimate reasons people, especially women, look for alternatives!) but also drops some important points like this:

But it’s important to remember that the dollars we drop on salt lampsand Moon Dust aren’t the same thing as agitating for change—and that retreating into wellness is only an option for the privileged set. Medical outcomes in the US are largely predicted by race and socioeconomic status, and it is minorities and poor people who face the worst consequences when toxins get dumped and regulatory systems break down.

Dear Gwyneth Paltrow, we’re not f**king with you, we’re correcting you. XOXO, science (5.22.17 via Dr. Jen Gunter) Dr. Gunter is a damn delight, and taking on the snake  oil salesman ways of Goop is a frequent topic on her blog. This is one of several take downs Dr. Gunter has done, all of which are informative, science and fact-based, and often hilarious as she deconstructs Goop’s latest fad with incredulity.

Wellness, womanhood, and the west, how Goop profits from endless illness (4.28.17 via Jezebel)  Stassa Edwards is really fantastic and you should read this whole thing.

Learning to chew, swallow, and shit at Viva Mayr, an Austrian Detox spa for the ultra wealthy (3.15.17 via Jezebel) I read this with an open, non-judgemental mind, just because I think it was really interesting to hear about how Detox spas like this work. It reminded me of an older article from the Cut on a celebrity weight loss “wellness” retreat, and I think both articles provide some important observations on the pros and cons of these spas/camps/retreats that you really cannot make without some first hand experience.

Healthy Outdoor Spaces & Environmental Pollution

A plastic bottle floats in the Darby Creek.

The first time my partner and I used our inflatable tandem kayak (yes, I know that’s very dorky but we’re renters and don’t have space for a real kayak) we took it to the John Heinz National Wildlife Refuge at Tinicum to go out in Darby Creek. We had been to the Heinz before, but on foot. The Heinz is the nation’s first “urban refuge,” established in 1972 to preserve the marshland and the ecosystem that relies on it.

Last year while I was taking a class on environmental public health for my MPH degree, we had Josh Barber, the EPA Remedial Project Manager at the Clearview Landfill come speak to us about Superfund sites. The Clearview Landfill is located above the Heinz, while the Folcroft Landfill is located downstream, partially in the Heinz. Both landfills are Superfund designated sites, which are highly polluted areas identified by the government for remedial action in the interest of environmental and human health.

That big body of water is the Heinz refuge. Image from:

So this was in the back of my mind, but I didn’t think much of it until we we lugging our equipment out and passed a paddle boarder who was leaving the Creek. He asked if we were headed down to the boat launch.

“It’s gross,” he said. He explained he’d been in bodies of water all around Philadelphia, but Darby Creek seemed to be the most litter-filled and brown. He said he was glad he was an experienced paddle boarder and didn’t fall in. My partner and I got our kayak out and went out anyway, but on the water, it was hard to not think about litter since every few feet or so, we passed more plastic bottles, condoms, soda cans, and unidentifiable plastic pieces.

The US Fish and Wildlife Service page for the Heinz even lists out 10 points of interest for those going out in canoes and kayaks to look for, which includes the Folcroft Landfill, a Sun Oil tank, and a sewage treatment plant. Scenic!

It’s hard to escape visual reminders of the pollution that impacts Darby Creek
Trash collects in little islands along with fallen branches in Darby Creek

For people living in large, urban areas like Greater Philadelphia, access to nice outdoor spaces is really important for human health. I grew up in Maine, and access to nature was definitely something I took for granted because it just… wasn’t something I had to think about. It was everywhere. Since I’ve lived in Philadelphia for almost 10 years, getting out into green spaces is something I have to be more intentional about.

In my public health classes we frequently discuss interventions that are aimed at improving population access to outdoor spaces and increasing the amount of time people spend outdoors being physically active. In Philadelphia, pediatric doctors are now even prescribing children with time out in nature as part of the NaturePHL partnership to increase physical activity.  Even small modifications to urban environments, like cleaning and greening vacant lots, can have an impact of residents’ health and stress levels.

So… what happens when those outdoor spaces are polluted? 

Environmental pollution has very real impacts on human health. For the Eastwick community that surrounds the Heinz and the Folcroft and Clearview Landfills, they have long reported elevated rates of asthma and cancer, believed to have come from their polluted environment besieged by frequent floods. Dr. Marilyn Howarth (who taught the class I took when I originally learned about the Heinz as a Superfund site) recently did an interview with the Philadelphia Inquirer where she spotlighted the issues in Eastwick:

If your only exposure is to a particular chemical in the soil that might be left over from a hazardous waste site, in and of itself, it might not pose a very big risk to you for cancer or some other health effect. But say you are being exposed at the same time to air pollution from a nearby highway, and you’re also close to refineries that have emissions, even if those emissions are lower than allowed by their permit. Adding all these together, the opportunity for these exposures to cause you harm increases.  The varied exposures  might be working on the same body parts and the same mechanisms of causing disease. That cumulative exposure might mean you’re more likely to get the disease than if you’re exposed to any one toxic chemical singly.

This concept of cumulative exposure is pretty important, because interacting with one’s accessible outdoor environment is generally thought to be healthy, however, many people are not so lucky if the actual environment is itself unhealthy! Studies have found that poor, minority-majority neighborhoods are more likely to be exposed to higher levels of air pollution, and that minorities and low-income individuals are more likely to live near a toxic waste site.  In old cities like Philadelphia, lead-contaminated soil is a concern for developers, gardeners and children playing outside.

The amount of trash in a space is often a factor in whether you decide to hang out there or not. Trash is unfortunately pretty much ever-present in Philadelphia (we’re trying to be better!), and on top of the more-unseen environmental pollutants like air quality and lead in soil, I know for me personally, I’d much rather hang out in a park that appears clean than one filled with a bunch of gross litter. Clean outdoor spaces influence people to spend more time outside where they are more likely to be physically active and outdoor spaces in poor condition influence people to stay inside, where people are more likely to be sedentary.

That said, individual bottles and pieces of plastic in the creek aren’t probably a huge threat to my personal health, but I am definitely not going out of my way to touch the water. There are still tons of turtles, fish, and birds in the Heinz but their health is most likely negatively impacted by the amount of trash in their living space! People who have lots of easy, close access to pristine outdoor spaces are very privileged, but should also feel pressure to help maintain the cleanliness of those spaces. Trash is something that all humans produce, but where where that trash ends up is often where people already have less access to outdoor spaces and fewer social and economic resources to enjoy outdoor spaces.

So if you’re feeling kind of Not-In-My-Backyard about trash- remember the earth is everyone’s backyard! Clean spaces and less trash are better for everyone.