Over the past three decades, US mortality rates resulting from suicide, drug overdose, and alcohol-related liver disease-collectively referred to as Deaths of Despair (DoD)-have risen sharply. While epidemiologic patterns are well documented, less is known about the lived experiences of those vulnerable to DoD and the factors that support recovery. This study partnered with an addiction recovery center in a central Pennsylvania community disproportionately affected by despair-related conditions. Seventeen individuals in active recovery participated in in-depth interviews to explore pathways leading to despair and addiction, and sources of resilience. Thematic analysis using MAXQDA software identified three primary themes with subthemes: barriers to recovery (grief from personal loss, isolation, and ineffective coping with pain), shifts from despair (ie, "moments of clarity") (change in motivation, remorse, and embarrassment), and recovery support (higher power and family, community and healthcare support). These findings provide qualitative insight into the biopsychosocial dynamics of despair and recovery and highlight the importance of grief support, coordinated pain management, emotional reflection, and social and spiritual resources. Such insights may inform clinical practice, community programs, and policy interventions aimed at reducing DoD and supporting long-term recovery.

This essay explores personal and cultural meaning in dementia through the respective stories of biomedicine, public health, and alternative worldviews, using Indigenous perspectives as a critical example. Since Alzheimer's visibility as a biomedical illness intensified in the 1970s, the disease has generated powerful narratives of scientific cure that are now limiting public discourse and appropriate social and ecological action. In this essay, our approach is rooted in the recognition that stories in their many forms (oral, written, embodied, and visual) and their associated metaphors create the semantic webs of words and actions that endow human beings with meaning. New stories from less medicalized spaces can both challenge the often-unrecognized limits and damaging behaviors of profit-driven, scientific reductionism and revitalize public and ecological health approaches based on expanded worldviews of individual, social, environmental, and indeed planetary health.

Objectives: We evaluated the effectiveness of a community-facilitated, digital application intervention at increasing physical activity in central Pennsylvania. Methods: We employed a game-based digital application within partnership- guided, nature-based programming to encourage physical activity. Partnerships with local healthcare and park/ recreation entities were established to facilitate recruitment and intervention sustenance. Self-reported psychological and physiological changes were evaluated in a repeated-measures design, contextualized by thematic coding of qualitative responses, and interpreted via the Park Prescription Theory of Change. Results: Partnerships were formed among 3 local healthcare entities, Berks Nature, and community organizations to conduct the intervention. There were increases in physical activity duration and time spent outdoors. We identified positive, consistent trends in perceptions of healthful behaviors and quality of life, health satisfaction, and perceived accessibility and barriers. There were low rates of allergies or wheezing. The game-based application improved sentiments of belongingness and familial engagement. These findings mostly aligned with the Park Prescription Theory of Change. Conclusions: An innovative, cross-disciplinary means to improve physical activity can inform approaches at the regional or national level, as well as guide legislative efforts in public health, environmental policy, and urban planning.

In response to Finch and Burstein's provocative argument that the advanced dementias may result from environmental toxins and lifestyle factors associated with post-industrial societies, we call for a more rigorous historical approach, emphasizing the importance of situating ancient texts more fully in their historical and cultural context. Such an approach would also entail consideration of the declining relative rates of dementia in Western countries, which have been linked to population health-level factors and policies that appear to have reduced the risk of dementia by directly and indirectly influencing the social determinants of brain health.

Deaths of Despair (DoD), or mortality resulting from suicide, drug overdose, and alcohol-related liver disease, have been rising steadily in the United States over the last several decades. In 2020, a record 186,763 annual despair-related deaths were documented, contributing to the longest sustained decline in US life expectancy since 1915–1918. This forum feature considers how health humanities disciplines might fruitfully engage with this era-defining public health catastrophe and help society better understand and respond to the crisis.

As part of community health needs assessments, US nonprofit hospitals are identifying a high prevalence of chronic diseases associated with poor diets. Institutions have responded by establishing nutrition-related initiatives such as farmers' markets and community gardens. There is public health value in demonstrating how these partnerships can help hospitals address identified community health needs. Here we describe diverse strategies undertaken by a hospital-based community garden at Penn State Milton S. Hershey Medical Center, explore implications for US hospitals, and provide implementation guidance. (Am J Public Health. 2023;113(9):939-942. https://doi.org/10.2105/ AJPH.2023.307336)

The Accreditation Council for Graduate Medical Education's (ACGME) 2021 Clinical Learning Environment Report (CLER) found that recognition of health care disparities and social and environmental impacts of health among medical residents and fellows remains limited.1 Given the increasing population of older individuals and individuals of non-White backgrounds, medical educators must promote innovative educational strategies that facilitate students' ability to provide effective care and better outcomes. While didactic learning about social determinants of health (SDH) is critical for medical education,2 understanding the ways SDH contribute to health disparities may be best achieved through community-embedded experiences for students3 (Figure 1). Our experience leading a community-based initiative with resettled refugees has been a powerful means of understanding and intervening in the structures, institutions and social processes that generate health disparities. Our experience leading a community-based initiative with resettled refugees has been a powerful means of understanding and intervening in the structures, institutions and social processes that generate health disparities. The PSCOM Refugee Initiative (RI) began in 2016, and is a free-standing, medical student-led organisation of approximately 10 volunteers funded by a Pennsylvania state grant secured by student leaders.4 Originally, a dozen resettled Syrian refugee families in Harrisburg, PA, were enrolled in the RI, receiving tutoring services at a local mosque and carpooling to a farmer's market to buy fresh subsidised produce. Due to increased needs, the programme has evolved beyond tutoring and food security to include transportation, volunteer assistance with adult English learning, medical translation and donations of clothing and furniture. However, in spring 2020, our organisation and the families we served faced new challenges due to the COVID-19 pandemic.5 As the pandemic unfolded, the farmers' market we had visited weekly for years closed, and several families lost their only source of income due to COVID-19-related layoffs. With looming deadlines for rent and utilities, we were initially overwhelmed by the urgency to provide assistance, since we lacked the power to redirect our funds due to the state grant's funding structure. However, thanks to our broader community, we used an online crowdfunding platform to fundraise over $10,000 in rescue funds in 3 days. In November 2020, we resumed market trips, contributed donated funds towards basic needs like housing and utilities as they arose and assisted families with unemployment assistance applications. However, even for native English speakers, this proved difficult. Online forms were surprisingly complex, and calling social services was futile due to consistently busy phone lines. Meanwhile, ad hoc interpretation by bilingual volunteers helped communication between refugees and social services in the short term, but we experienced stress and occasional inaccuracies in employing these informal translation services. Working closely with populations in need helped us better appreciate the SDH, inequities and challenges faced by resettled refugee populations. Navigating complexity across multiple domains presented us with a real-time window for seeing and responding to exigent SDH in ways that were instructive for our pedagogical development. We engaged in interdisciplinary teamwork, working with refugee families, non-profit organisations, state grant officers and community members to help secure food, housing and employment. Through it all, we observed parallels between coordinating with community partners to help refugee families and working in inpatient interdisciplinary teams to treat patients. As a result of this experience, we are well positioned to care for vulnerable populations with SDH in mind. As future residents and fellows, our awareness of SDH will impact the health outcomes of our future patients (Figure 2). Through it all, we observed parallels between coordinating with community partners to help refugee families and working in inpatient interdisciplinary teams to treat patients. We have considered our experience with the RI's model, including its advantages and drawbacks. Ultimately, having a free-standing, student-led organisation provided ample opportunity for creative freedom, flexibility and improvisation among the student volunteers in coordination with refugee families. Service learning, in which structured community service projects are integrated into the medical curriculum, has been established as a valuable model for incorporating community perspectives into medical education.6, 7 However, we have found value in having students self-select for service on the basis of their intrinsic passion rather than formal requirement. Lack of formality is a double-edged sword, and there are inherent limitations to this more free-standing model. In our experience, these included challenges in maintaining sustainable community-academic partnerships and reliable student volunteer commitments. Throughout our term, students created connections between the RI and the state Department of Health's refugee services team, local places of worship and non-profit organisations. However, because students commence core clerkships after a 1-year leadership term, these connections are difficult to sustain. Prior initiatives have shown that establishment of a multi-disciplinary executive board composed of not only transient student leaders, but committed faculty and agency staff has been effective in mitigating this issue.8 Our experience suggests that other key stakeholders might include refugees, public health officials, and community organisations. Subsequent selection of a student volunteer base—supervised by the longer-term executive board—who agrees to a partnership with a refugee family for a one-year term has also been effective in other organisations.8 In addition to the value in having refugee initiatives run by medical students that are free-standing and voluntary, it is also worth thinking about ways concepts from this work could be fruitfully integrated into medical curricula to benefit the broader student body. At PSCOM, we shared the benefits of our community engagement by including refugee families as part of PSCOM's 'Patient Navigation' programme, which pairs students with patients to help them navigate the health care system. Other avenues may be to integrate modules about refugee populations into existing coursework in Clinical Skills, Humanities, or Health Systems courses. Problem-based learning (PBL) sessions, case studies or panel discussions could also be built based on real-world student experiences with SDH to provide simple and effective administration of key takeaway points to the entire class. Such refugee health modules have been successfully implemented at other institutions.9 In addition to the value in having refugee initiatives run by medical students that are free-standing and voluntary, it is also worth thinking about ways concepts from this work could be fruitfully integrated into medical curricula to benefit the broader student body. We have presented our work at national public health conferences and continue to collaborate with colleagues at other institutions and agencies across the country to improve similar refugee initiatives. Through a high standard of constant evaluation and innovation, our RI and similar programmes can uplift the competency of graduating medical students in applying SDH in their future medical practice. Mariam A. Shalaby: Conceptualization; project administration; writing—original draft; writing—review and editing. Kayla J. Krause: Conceptualization; project administration; writing—original draft; writing—review and editing. Raisha Ismail: Conceptualization; project administration; writing—original draft; writing—review and editing. Jed D. Gonzalo: Conceptualization; resources; supervision; writing—review and editing. Daniel R. George: Conceptualization; project administration; supervision; writing—original draft; writing—review and editing. The authors would like to thank Daniel Wolpaw, MD, for his support and editorial comments, their fellow student leaders of the Refugee Initiative, the organisations with whom they worked and the refugee families with whom they collaborated during 2020-2021. Thanks is also owed to Noha El Komi for her design of the figures featured in this article. The authors have no conflicts of interest to report. This article does not describe human subject research, but rather experience with community engagement. As such, human subject protection approval was not warranted. The names and identifiable information of individuals with whom we worked are omitted here to preserve privacy.

Opening Minds Through Art (OMA) is a standardized expressive arts-based program that improves student attitudes toward persons living with dementia. Understanding how this change occurs is important for both educators and clinicians. In this study, narrative analysis was used to explore the impact of OMA on participating medical students. 111 students at six medical schools accepted an invitation to be part of OMA during the 2018-2020 academic years. After completing the program, participants were asked to write briefly about the impact of their OMA experience on their work as future physicians. These narratives were analyzed to identify themes relevant to the impact of the program. Students described appreciating both pragmatic and novel creative experiences in OMA, which differed from their traditional studies. Themes from the evaluation included: Inter and Intrapersonal Connection and Growth; Mastery of Anticipated Challenges; Acquisition of Knowledge and Skills; and Appreciation of Health Care Team Members. Teaching students to embrace clinical work with challenging and perceived "difficult" patients is often unaddressed in the medical school curriculum. This study suggests that the combination of medical knowledge and artistic expression can be used to benefit both students and persons living with dementia.

Objectives To assess associations between diseases of despair (DoD) and incident atherosclerotic cardiovascular disease (ASCVD) among insured adults in the USA.Design Retrospective cohort study.Setting Highmark insurance claims data in the USA from 2017 to 2021.Participants Adults with at least 10 months of continuous insurance enrolment, no record of ASCVD in the 2016 baseline year and no missing data on study variables.Primary and secondary outcome measures Cox proportional hazard regression was used to calculate crude and adjusted hazard ratios (HR) and 95% confidence intervals (CI) to assess risk of ASCVD (composite of ischaemic cardiomyopathy, non-fatal ischaemic stroke, peripheral arterial disease or non-fatal acute myocardial infarction) by baseline DoD overall, and by the component conditions comprising DoD (alcohol-related disorders, substance-related disorders, suicidality) individually and in combination.Results The DoD-exposed group had an age-adjusted rate of 20.5 ASCVD events per 1000 person-years, compared with 11.7 among the unexposed. In adjusted models, overall DoD was associated with increased risk of incident ASCVD (HR 1.42, 95% CI 1.36 to 1.47). Individually and in combination, component conditions of DoD were associated with higher risk for ASCVD relative to no DoD. Substance-related disorders were associated with 50% higher risk of incident ASCVD (HR 1.5, 95% CI 1.41 to 1.59), alcohol-related disorders and suicidality/intentional self-harm were associated with 33% and 30% higher risk, respectively (HR 1.33, 95% CI 1.26 to 1.41; HR 1.30, 95% CI 1.11 to 1.52). Co-occurring DoD components conferred higher risk still. The highest risk combination was substance-related disorders+suicidality (HR 2.01, 95% CI 1.44 to 2.82).Conclusions Among this cohort of insured adults, documented DoD was associated with increased ASCVD risk. Further research to understand and address cardiovascular disease prevention in those with DoD could reduce costs, morbidity and mortality. Further examination of overlapping structural factors that may be contributing to concurrent rises in ASCVD and DoD in the USA is needed.

Background: Given the challenges of developing disease-modifying treatments for Alzheimer’s disease and related disorders, non-pharmacological interventions represent an increasingly promising approach in long-term care settings. Music-based interventions have been effective in improving the quality of life by influencing biopsychosocial factors that play a role in the progression of illnesses such as depression and anxiety. However, approaches have tended to focus exclusively on the person with dementia rather than integrating caregivers. Objective: This study aimed to determine the impact of a music-based intervention on the quality of life of persons with dementia and their caregivers. Methods: A mixed-methods study was conducted with seven dyads consisting of residents (aged 76–92) with diagnoses of dementia and their caregivers (aged 53–84) at a skilled nursing facility in Pennsylvania. Eight music intervention sessions were completed in the presence of the resident and caregiver using personalized playlists created for the dyad. Pre- and post-intervention questionnaires were administered during each session, and observational data for both residents and caregivers were collected. Results: Caregivers reported feeling less overwhelmed after the intervention with a mean difference of –0.24±0.14, p = 0.016. Mean difference in the other 5 responses showed that listening to music had a beneficial impact for resident/caregiver dyads. Observations of interpersonal behavior supported the benefit of the intervention for these dyads. Conclusion: Quantitative analysis of a personalized music intervention for residents/caregivers showed positive trends in increasing personal connection, and qualitative data identified greater appreciation of the relationship and increased bonding.

German philosopher George Wilhelm Friedrich Hegel once wrote that “the owl of Minerva spreads its wings only with the falling of the dusk.” In other words, it is only in hindsight, after the events of an era have transpired, that we can truly comprehend their historical import. In How Not to Study a Disease, neurobiologist Karl Herrup attempts a retrospective look at the myriad failures that have delivered the Alzheimer’s field into its current predicament, and seeks to chart a wiser path forward. Herrup is chiefly concerned with examining how the amyloid cascade hypothesis became a totalizing force in the field (“if you’re not studying amyloid, you’re not studying Alzheimer’s”, he was told early in his career), and why fealty to this model has failed to produce effective treatments despite billions of dollars and the work of countless researchers. His analysis implicates a broad swath of factors in the cul-de-sac of amyloid-based approaches. A political calculus that has, since Emil Kraepelin’s decision to declare Alzheimer’s a disease of plaques and tangles, consistently overruled common sense and inflated the likelihood of a cure; groupthink that led to the rejection or suppression of findings inconsistent with the amyloid cascade hypothesis; a quasi-religious faith in the power of genetics and pharmaceuticals to solve problems; industry incentives aligned with commercial profit rather than quality science; corrupt patronage systems of experts well-funded by industry and motivated by fame, reputation, and power; a compliant media that has failed to ask the hard questions when approaches clearly haven’t worked. All of this is, from Herrup’s birdseye view, decidedly not how you study a disease. Of course, it is fair to question why Herrup’s critique is being leveled now rather than in prior decades when aggressively challenging the field’s guiding myths and orthodoxies carried far greater consequences. This deepens admiration for those voices that spoke up against the amyloid-centric theories, conceptual errors, and misguided values and priorities of the field when the professional costs for doing so were much more severe. Herrup is not so much leveling a new critique as synthesizing countervailing views previously expressed by past “heretics” who history has proven correct. Nevertheless, Herrup argues that any path out of the current crisis will require a redefinition of Alzheimer’s disease—one that is unfettered by the sclerotic amyloid-cascade hypothesis. He proposes a biological reconceptualization based on what he calls a “Neighborhood model”. This “connectomics” approach begins by understanding the local interactions among different neural cell types (i.e., neighborhoods) and then working outwards in complexity to “cities” and “nations” to conceptualize how advancing loss of local functionality across vast interconnected networks could precipitate the emergence of dementia. Such a model is not novel, but may provide a better heuristic for conceptualizing a syndromal condition that is heterogeneous, age-related, and complex than the single-mechanism theories that have so paralyzed the Alzheimer’s field. Herrup also shares numerous recommendations to tweak funding mechanisms to steer resources to non-amyloid researchers, which—while certainly needed—is perhaps a tad self-serving. One major change he suggests is to defund the amyloid police at

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Food systems influence environmental sustainability and health. The fact that our current food production and distribution practices neither support nor promote planetary or human health raises ethical concerns. Since health organizations offer food to patients, community members, and employees, they are situated at key intersections among food systems, agricultural policies and practices, and public health. This article considers the nature and scope of health care organizations' local food system leadership responsibilities and describes how health care organizations' food practices can help improve health outcomes and motivate equity.

INTRODUCTION There is presently a rural hospital shortage in the United States with 180 closures since 2005 and hundreds of institutions in financial peril. Although the hospital closure phenomenon is well-established, less is known about the spillover impact on the operations and financial wellbeing of surrounding hospitals. This preliminary study quantified how discrete rural hospital closures impact institutions in their regional proximity, finding a significant increase in inpatient admissions and emergency department visits for these "bystander hospitals". METHODS Using a repository of rural hospital closures collected by the UNC Sheps Center for Health Services Research, we identified closures over the past 15 years. Criteria for inclusion were hospitals that had been fully closed between 2005-2016 and with >25-bed capacity. We then designated surrounding hospitals within a 30-mile radius of each closed hospital as "bystander hospitals." We examined the average rate-of-change for inpatient admissions and emergency department visits in surrounding hospitals both two years before and after relevant hospital closures. RESULTS We identified 53 hospital closures and 93 bystander hospitals meeting our criteria during the study period. With respect to geographic distribution, 66% of closures were in the Southern US, including 21% in Appalachia. Average emergency department visits increased by 3.59% two years prior to a hospital's closure; however, at two years post-closure the average rate of increase rose to 10.22% (F (4,47) = 2.77, p = 0.0375). Average bystander hospital admissions fell by 5.73% in the two years preceding the hospital closure but increased 1.17% in the two years after (F (4,46) = 3.05, p = 0.0259). CONCLUSION These findings predict a daunting future for rural healthcare. While previous literature has described the acute effects hospital closures have on communities, this study suggests a significant spillover effect on hospitals within the geographic region and a cyclical process at play in the rural healthcare sector. In the absence of significant public health assistance in regions affected by closures, poor health outcomes, including "diseases of despair," are likely to continue proliferating, disproportionately affecting the most vulnerable. In the COVID-19 era, it will be especially necessary to focus on hospital closures given increased risk of maintaining solvency due to delayed and deferred care atop already tight margins.

AbstractBackgroundResearch of hypertension‐related risk factors for Alzheimer's disease has typically focused on blood pressure (BP) levels, despite evidence that high blood pressure variability (BPV) over time may predict poorer cardiovascular, neuropathological, and neurocognitive outcomes. We evaluated associations between BPV and cognitive function in the Multi‐Ethnic Study of Atherosclerosis (MESA).MethodsMultivariable linear and logistic regression analyses of BP data across six examinations were used to determine associations that BPV (average real variability [ARV], variability independent of the mean [VIM]) and group‐based latent BP trajectories have with cognitive function, decline, and impairment, measured by the Cognitive Abilities Screening Instrument (CASI), Digit Symbol Coding (DSC), and Digit Span tests.ResultsParticipants (N = 1314; mean baseline age = 57) were 50% female, and 48% White. Higher systolic (β = −0.06, 95% confidence interval [CI]: −0.12, −0.0001) and diastolic (β = −0.08, 95% CI: −0.14, −0.02) ARV predicted increased global cognitive decline after covariate adjustment. Stronger relationships between BPV and global cognition were in older, White and Black participants, apolipoprotein E (APOE) ε4 non‐carriers, male participants, and non‐antihypertensive medication users.ConclusionResults suggest that higher systolic and diastolic BPV is an independent risk factor for cognitive dysfunction and decline in this multi‐ethnic cohort. This relationship differs across demographic and clinical characteristics.