Category Archives: Faces of Public Health
Behavioral health was a frequent topic at this year’s Preparedness Summit in Atlanta for both presenters and attendees, who focus on helping people cope with stress during a disaster as well as on mental health conditions which can be exacerbated by the stress of an emergency. Thomas Bornemann, EdD, has been the director of mental health programs at the Carter Center in Atlanta since 2002. The Carter Center is the philanthropic foundation of former president Jimmy Carter and his wife, and focuses primarily on peace and health initiatives globally and in the United States.
NewPublicHealth spoke with Bornemann about the Center’s mental health programs and challenges that lie ahead. We spoke with Bornemann several days before the shooting this week at Fort Hood.
NewPublicHealth: What are the key mental health projects underway at the Carter Center?
Thomas Bornemann: We’re involved in a number of issues at the local level, national level and globally. One of our major global programs is a program in Liberia, West Africa, where we’ve been working on scaling up services in this post-conflict, low-income country. We are in our fourth year of five, and we’re providing three services: We’re training mental health workers because their mental health system was decimated after the war; we have helped them develop a national mental health policy plan and a national mental health law that will go to the legislature for approval this year we hope; and we’ve been working on the issues of stigma and discrimination against people with mental illnesses and helping to develop support for family caregivers who provide the lion’s share of the care.
In the United States we’ve been working for years on Mrs. Carter’s number one healthy policy priority, which has been the implementation of mental health parity legislation which passed in 2008. The U.S. Department of Health and Human Services has been working on final regulations since then which spell out the terms and conditions of parity. We’ve been working on monitoring that through the years, and we were very proud that in November Secretary Kathleen Sebelius came here to announce the release of the regulations out of respect for Mrs. Carter’s long commitment to parity legislation. We’ll continue to monitor the parity efforts as they become implemented through the Affordable Care Act.
NewPublicHealth will be on the ground in Atlanta next week for the 2014 Preparedness Summit, an annual event since 2006 convened by the National Association of County and City Health Officials (NACCHO) and other partners including the U.S. Centers for Disease Control and Prevention (CDC) and the American Red Cross. Summit attendees include preparedness professionals working in local, state and federal government, emergency management, volunteer organizations and health care coalitions.
Goals of the summit include opportunities to connect with colleagues, share new research and learn to implement model practices that enhance capabilities to prepare for, respond to and recover from disasters and emergencies.
Additional partners include the American Hospital Association; the Association of State and Territorial Health Officials (ASTHO); the Association of Schools and Programs of Public Health (ASPPH); the Council of State and Territorial Epidemiologists (CSTE); the Association of Public Health Laboratories (APHL); the Office of the Assistant Secretary for Preparedness and Response (ASPR); the U.S. Food and Drug Administration (FDA); the Medical Reserve Corps (MRC); the U.S. Department of Homeland Security (DHS); the National Association of Community Health Centers (NACHC); and the Veterans Emergency Management Evaluation Center (VEMEC).
In advance of the summit, NewPublicHealth spoke with Jack Herrmann, Senior Adviser and Chief of Public Health Preparedness at NACCHO.
NewPublicHealth: What are some important issues going on in disaster preparedness in the United States right now that make the Summit especially important this year?
Jack Herrmann: There have been significant budget cuts to the ASPR Hospital Preparedness Program, and that is going to impact local and state public health departments and health care facilities pretty significantly across the country. Hopefully the summit will provide a venue to better understand what those impacts might be and allow us as a community to voice our concerns to our political leaders around the impacts of those budget cuts. It will also provide some very substantive evidence for organizations such as NACCHO , ASTHO and others to advocate on behalf of our constituents.
NPH: What are some of the key plenary talks?
Herrmann: Sheri Fink, a correspondent at The New York Times, who is also the author of the Pulitzer Prize-winning book “Five Days at Memorial” about her experience during Hurricane Katrina, will be a keynote speaker. What we’re having her do during the session is look back to her experience during Hurricane Katrina and researching what happened during that time from a health care preparedness perspective—and the lives that were lost and the issues and challenges that health care facilities faced in the aftermath of that disaster—and looking at where we are now.
Louis W. Sullivan, MD, former U.S. Secretary of Health and Human Services under President George H.W. Bush, recently wrote a memoir, Breaking Ground: My Life in Medicine, that offers a wide view of Sullivan’s experiences as a medical student in Boston, the founding dean of the Morehouse School of Medicine in Atlanta and as the country’s chief health officer. NewPublicHealth recently sat down with Sullivan to discuss the book and his thoughts on the history and future of improving the nation’s health.
NewPublicHealth: Looking back, what can you share about the highlights of your career in medicine and health promotion?
Louis Sullivan: Highlights would certainly include my time at the Boston University School of Medicine. That had many significant points. It was my first time living in an integrated environment because up until that time I spent all of my life in the South. Working in an environment without concerns about discrimination and bias, that was a great experience; my classmates and the faculty at Boston University were all welcoming.
Another highlight was later when I was a research fellow in hematology in the Harvard unit at Boston City Hospital. I had a paper accepted for presentation at a major research conference in Atlantic City. It was a paper showing that heavy drinking suppressed the production of red blood cells by the bone marrow.
And of course a tremendous highlight was going back to Morehouse College, my alma mater, to start the Morehouse School of Medicine. I was returning home in a sense. I had gained experience as a faculty member at Boston University, had been steeped in medicine and now I was in the process of establishing a new institution to train young people for the future.
NewPublicHealth: What changes have you created and supported to improve population health.
Sullivan: Well, certainly becoming Secretary of Health and Human Services was indeed an honor and a great opportunity for me, and it was also a very challenging experience.
In the late ‘80s, when I became Secretary, AIDS was a new disease. There were many demonstrations by various advocacy groups, groups that didn’t trust the government, and we had to work to develop a relationship with them. I convinced President Bush to put $1.6 billion in his budget to be used for research on this new disease, to develop mechanisms for treating the disease and to educate the public. And as a result of that initial investment and ones that followed, this disease has been transformed from a virtual death sentence to a chronic disease which is controlled by medication. And people, rather than living a few months, which was the case once the diagnosis was made in 1989, are now living for decades with the virus suppressed on medication, raising their families, working, earning wages, paying taxes. So that has been really a very satisfying outcome from that experience. And we hopefully are close to finding a cure for this disease as well.
As the demand for walkable communities keeps growing, experts are moving from asking “If they build it, will they come?” to questioning how to fund the new developments, as well as keeping our eyes on issues such as transit, affordability and improving population health. As of January sharing best practices for those and many other issues is the job of Chris Zimmerman, who recently joined the staff of Smart Growth America as Vice President for Economic Development, following a very long stint as a member of the Arlington County Board in Virginia. Before his post in Arlington, Zimmerman was Chief Economist and Committee Director for Federal Budget and Taxation at the National Conference of State Legislatures. In his new role, Zimmerman will focus on the relationships between smart growth strategies and the economic and fiscal health of communities.
NewPublicHealth spoke with Zimmerman soon after he landed in his new office.
NewPublicHealth: What did you do before joining Smart Growth America?
Chris Zimmerman: For the last 18 years I’ve been a member of the Arlington County Board, the governing body of Arlington County, Virginia, an urban county of about 220,000 people right next to Washington D.C. The county functions as a comprehensive local government, with functions from school funding to land use and development to standard municipal functions such as parks and recreation, public safety, waste removal and managing public infrastructure. We don’t run the schools, but the funds for the schools are part of the county budget, at a cost of a little more than $1 billion annually.
Arlington County has become a model for transit-oriented development that is studied by folks around the country and even around the world, particularly because of the way the county has chosen to develop around the Metro system. That includes the initial commitment to be involved in Metro Rail, to fund underground Metro stations and then to focus development around them, beginning even before the ideas of the vocabulary of Smart Growth and urbanism had really gotten started, decades ago.
Prior to serving on the county board, I served on the county’s planning commission and a number of other commissions. So I’ve had about 20 to 25 years of involvement in the development of every aspect of the community, including housing, planning development and economic development, and even agencies such as the Washington Metropolitan Area Transit Authority, which runs Metro Rail and Metro Bus and every other regional transportation planning body there is here in Washington. I was involved in a lot of regional transportation issues that obviously were fundamental to our county because of the way we chose to develop and because of where we’re located. There are seven crossings of the Potomac River and five of them go through Arlington, so although there are a couple hundred thousand people in Arlington, there’s a million and a half or so in northern Virginia and large numbers of them go through Arlington every day.
Last year, the U.S. Department of Health and Human Services released updated national Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care to help health organizations improve care in diverse communities.
When the updated standards were released, Howard K. Koh, MD, MPH, the Assistant Secretary for Health in the U.S. Department of Health and Human Services (HHS), said “the enhanced CLAS Standards provide a platform for all persons to reach their full health potential.” Koh added that the updated CLAS Standards provide a framework for the delivery of culturally respectful and linguistically responsive care and services. By adopting the framework, health professionals will be better able to meet the needs of all individuals at all points of contact.
“As our nation becomes increasingly diverse, improving cultural and linguistic competency across public health and our health care system can be one of our most powerful levers for advancing health equity,” said Nadine Gracia, MD, MSCE, and Deputy Assistant Secretary for Minority Health and Director of the HHS Office of Minority Health.
NewPublicHealth recently spoke with Gracia about the updated standards and opportunities that efforts to increase health equity can bring to the health of individuals and communities.
NewPublicHealth: How does cultural respect help improve health in diverse communities?
Nadine Gracia: As we see the growing diversity of our country and the persistence of health disparities, really having everyone engaged in the discussion of health equity and the attainment of the highest level of health for all people is vital. Culture and cultural respect are really important when we talk about health equity as well as quality of care, and that’s because culture really influences health beliefs and practices. It influences one’s health-seeking behaviors and attitudes and the experience that someone may have in a health care setting.
So, it is essential that providers and health care delivery institutions understand the critical role that they play in providing culturally and linguistically appropriate services. We define those services as ones that are respectful of and responsive to an individual’s cultural health beliefs, their preferred languages, their health literacy levels and their communication needs. They are really applied by and employed by all members of an organization at every point of contact.
Culturally and linguistically appropriate services are essential when we talk about the health care encounter because they are increasingly recognized as being effective in improving the quality of services and increasing patient safety by preventing miscommunication; facilitating accurate assessment and diagnosis of a patient’s condition; and enabling everyone engaged in health services to truly develop an accurate and effective treatment plan.
Building on epidemiologic evidence that suggests that healthy behaviors are transmittable across social networks, Microclinic International, a nonprofit international organization based in San Francisco, leverages human relationships to address both non-infectious and infectious diseases such as diabetes and HIV/AIDS. The theory behind the Microclinic International is that if negative behaviors such as smoking, unsafe sex and overeating can be contagious, so can positive, healthy behaviors.
The organization operates through “microclinics” that consist of small groups of people who share access to education, technology and social support as they work together to prevent and manage a deadly disease. Founder Daniel Zoughbie says the organization is “built on social relationships and social capital rather than bricks and mortar.” Microclinic works with local partners through community-based workshops with trained facilitators.
NewPublicHealth spoke with Zoughbie about Microclinic’s potential to reduce incidence of disease, both in the United States and abroad.
NewPublicHealth: What gave you the idea for Microclinic?
Daniel Zoughbie: When I was a college junior at UC Berkeley I wanted to do a junior-senior year project that would involve rigorous research, but also have an immediate impact on a community in need. My grandmother passed away from diabetes many years ago and I realized that a disease like diabetes is relatively simple to prevent and manage, and yet it is a leading cause of death and disability around the world.
So, I came up with the microclinic concept and piloted it in the West Bank with scholarship funds I was awarded at Berkeley. From the initial success of that pilot project I was able to expand to Jordan and recruit colleagues who worked with me to help build the organization. And then we expanded further. Today we’re running three microclinic projects in Kenya, supported by Google and other funders, in Jordan, supported by organizations including the health ministry and Her Majesty Queen Rania Royal Health Awareness Society, and in Appalachia, Kentucky supported by funders that include the U.S. Centers for Disease Control and Prevention and Humana.
NPH: What is the concept behind Microclinic?
Zoughbie: One of the most significant spaces for the prevention and management of major disease epidemics is actually not the formal health care infrastructure of hospitals and clinics alone—it is the spaces of homes and businesses and places where friends and family come together and can positively influence behaviors, such as eating healthy food, walking together, engaging in physical activity and helping each other monitor health conditions. Or, these kinds of spaces can be transformed into places where diseases spread. Families can sit sedentary in front of televisions. They can eat junk food together, and choose not to check on each other in terms of health monitoring and taking medications.
Several weeks ago, the Harvard School of Public Health celebrated its Centennial with fanfare, fundraising and a panel discussion featuring world health leaders who are graduates of the school. Following the centennial, NewPublicHealth spoke with the School’s Dean, Julio Frenk, MD, MPH, PHD, who has a joint appointment at the Harvard Kennedy School of Government. He is also a former health minister of Mexico and a former senior fellow in the global health program of the Bill and Melinda Gates Foundation.
NewPublicHealth: What do you think have been the key changes in public health efforts since the Harvard School of Public Health was founded 100 years ago?
Julio Frenk: The 100 years that have passed since the School of Public Health was founded are not just any 100 years—they’re the 100 years with the most intense transformations in health in human history. We have seen a more than doubling of life expectancy since the school was founded. Around 1900, the global average for life expectancy was 30 years. At the end of the century, the global average was about 65 years. It more than doubled in the 20th century, and that increase has continued with some setbacks, most notably the AIDS epidemic in Saharan Africa. And we have had a qualitative shift not just in the level of mortality, but in the causes of death. So we went from a preponderance of acute infections to now a predominance of mostly chronic non-communicable diseases, and that’s an incredible transition.
A critical change is that the experience of illness became very different starting from the beginning of the 20th century. Before then, illness was mostly a succession of acute episodes, from which one either recovered or died. If you recovered, you went on to get your next acute illness. Now, illness is more a condition of living. People live with cancer. People live with AIDS. So that’s a big transformation of the patterns of health, disease and death.
Another big change is the emergence of complex health systems, and that’s—again—a process that started at the beginning of the 20th century. Before the 20th century, the social function of the sick was mostly trusted to undifferentiated institutions, such as the family or religious institutions, and it’s not until the 20th century when you see this incredible explosion of specialized institutions and specialized human resources, doctors, nurses and other health professionals. In the 20th century, healthcare is 10 percent of the global economy and employs millions of people, including eight million doctors. These are all profound transformations.
NPH: How has the training of students of public health changed in the last 100 years?
Frenk: There has been profound change. What happened at the beginning of the 20th century was the emergence of public health as a field of action. The practices of engineering emerged in Europe, especially with the rapid urbanization there starting around the 17th century, but then greatly expanded in the 18th century. Engineering allowed for access to clean water and taking care of waste, which resulted in some diseases coming under control. In the 19th century the discovery of microbiology gave rise to the abolishment of the germs as causes of illness. That is the junction that gives birth to public health, along with the idea of social policy, of social activism that actually changed social conditions. It’s in that mix that public health gets shaped.
More than 145 million adults now include walking as part of a physically active lifestyle, according to a report released by the U.S. Centers for Disease Control and Prevention (CDC) earlier this year. More than 6 in 10 people walk for transportation or for fun, relaxation, or exercise, or for activities such as walking the dog. The percentage of people who report walking at least once for 10 minutes or more in the previous week rose from 56 percent in 2005 to 62 percent in 2010.
But creating communities amenable for walking takes much more than the proverbial “putting one foot ahead of the other.” Over the last decade, more and more communities have done local walkability assessments, added sidewalks, installed or improved crossing signs and signals, and vastly increased programs such as Walking School Bus, which encourages parents and kids who live a mile or less from school to join safe walking programs.
And behind most of these advances is a walkability advocate who knows the transportation chiefs, the local policymakers and the laws in other jurisdictions that promote or dissuade walking. In Boston, that person is Wendy Landman, executive director of WalkBoston, a non-profit membership organization dedicated to improving walking conditions in cities and towns across Massachusetts.
“Our goal is to make walking and pedestrian needs a basic part of the transportation discussion,” says Landman.
NewPublicHealth spoke with Landman at WalkBoston’s central Boston offices during our visit to the city for the recent American Public Health Association annual meeting.
NewPublicHealth: Why is walking advocacy so important?
Wendy Landman: At WalkBoston we sometimes describe walking as the club that everybody belongs to and nobody joins. Because it’s such a basic element of what every human being does, walking often gets forgotten, and it gets forgotten in many different ways. At the most basic level, walking is often left out of land-use planning and civil engineering. We forget to incorporate sidewalks and safe-street crossings. We forget to design and build our communities so that people can actually walk between places—whether it is kids walking to school or to a friend’s house, or adults walking to shops or church. That’s not to say that we should all live in a scale that’s just walkable, but many things that we do every day, day in and day out, would be better for human beings and for the planet if we could walk to some of them.
Since 2008, local health departments have cut nearly 44,000 jobs, according to a recent survey conducted by the National Association of County and City Health Officials. Although workforce losses and gains were roughly equal in 2012, 41 percent of local health departments nationwide experienced some type of reduction in workforce capacity and 48 percent of all local health departments reduced or eliminated services in at least one program area. Currently, local health departments reporting cuts still exceed the percentage of local health departments reporting budget increases.
California’s Napa County has dealt with its budget cuts by revamping its health department in order to continue to stay on mission.
“I think we've come out the other end of all this as a much stronger health department,” said Karen Smith, MD, MPH, Health Officer and Deputy Director for Public Health at Napa County Health and Human Services. “We moved from what I think of as an ‘old style’ [public health agency] to a department that focuses on our role as a convener/partner, providing expertise and leadership, and helping to craft policy.”
NewPublicHealth recently spoke with Smith about the methods Napa Public Health used—and that other departments might follow—to adapt and improve in the face of budget cuts.
NewPublicHealth: How have budget changes impacted your department over the last five to ten years?
Karen Smith: Napa Public Health started out with a lean health division for the size of the county compared to some of our colleagues, and we remain lean. We have not really decreased services, however. We were able to get out ahead when we saw looming budget constraints.
Napa Public Health is part of the County’s Health and Human Service Agency, which includes social services, as well as mental health, drug and alcohol, child welfare services, comprehensive services for older adults and public health, and our administrative divisions. The previous director had a distinctive approach to budgeting: that the agency has a bottom-line budget and within that we have very detailed division budgets. So I have excruciatingly detailed budgets for every single program within public health, and that was crucial to our being able to respond to the budget shortfalls in creative ways that had limited impact on services.
Lipstick & Liquor, a recently released documentary, takes a close-up look at a secret that is killing women and harming their families. Excessive alcohol use is the third leading cause of preventable death among women between the ages of 35 and 55. Excessive drinking among women is also a contributing factor in one-third of suicides, one-fourth of accidental deaths and one-half of traffic deaths. Significantly, drinking is more likely to reach advanced stages before it is discovered.
The film, which will launch on iTunes and Amazon.com in December, shares the stories of four women and their struggles with alcoholism. The goal of the film, says Lori Butterfield, the film’s writer and producer as well as a senior vice president of creative content for Home Front Communications, is to help women everywhere shake off the stigma associated with women alcoholics, and to provide understanding and insight into the struggle to stay sober. The documentary includes expert commentary from medical researchers, addiction specialists and authors who shed light on the conditions impacting the increase in alcohol use and abuse among American women.
NewPublicHealth recently spoke with Lori Butterfield about the film.
NPH: How did the documentary come about?
Lori Butterfield: My interest in raising awareness began with a story about a woman named Diane Schuler. In the summer of 2009, Diane made headlines after killing herself and seven other people while driving the wrong way on the Taconic Parkway in Westchester County, New York. The toxicology report showed that Diane had been drinking and yet her husband and other family members came out very publicly and said, “Oh she would never do that, she was a wonderful mother, she was a perfect wife.” And I remember thinking at the time, how could someone hide their alcoholism so well that their own family had no idea? That story really stuck with me.
Then, in November of that year, I was overseeing a video project for an Ad Council campaign about “Buzzed driving” [see recent Buzzed Driving campaigns from the Ad Council]. That’s when I read a very startling statistic. It said the number of DUI arrests for women had shot up more than 30 percent in the last decade while the rate for men was actually going down. And I also read that binge drinking for women was on the rise, so something was happening, but I wasn’t quite connecting the dots.