Category Archives: Q&A
Beginning later next year, more than a million workers in New York City will have a brand new, health-promoting benefit: paid sick leave days that guarantee wages on a set number of days when they or a family member they care for is ill.
The new law, passed last June by the New York City Council and overriding an earlier veto by the mayor, begins to go into effect in April 2014. New York now joins San Francisco, Calif., Washington, D.C., Seattle, Wash., Portland, Ore., and the state of Connecticut in adopting at least some sick leave provisions.
Not every employee in New York City will get paid sick leave under the new law. The bill that passed the City Council initially applies only to businesses with 20 or more employees, who will be required to provide five paid sick days a year; that extends to companies with 15 or more employees beginning October 1, 2015. Smaller businesses and manufacturing firms are exempt from the paid leave provisions for now, though these workers will gain five days of unpaid sick leave, so they can take time off without fear of losing their jobs. Advocates hope to extend paid leave to cover those workers before long.
Advocates say paid sick leave is critical for smaller businesses, and especially for low wage earners. A survey by the Community Service Society (CSS) of New York found that half of low-income respondents said they have less than $500 to fall back on in case of an emergency, and according to CSS, without compensation for sick days, people are often forced to choose between caring for themselves or a loved one and heading to work.
A 2012 study in the American Journal of Public Health shows why the measure that is critical to individuals and families is equally crucial to society as a whole. The study found that lack of certain workplace policies, including paid sick leave, led to an additional 5 million cases of adult H1N1 (swine flu) during the 2009 outbreak.
Funding for much of CSS’s advocacy came through a County Health Rankings & Roadmaps grant to focus on four areas in two New York City boroughs, the Bronx and Brooklyn, that have very poor health rankings. The goal was to build support among small businesses, faith-based organizations and low-wage workers for passage of the ordinance through grassroots events, town halls, story collection and media coverage, as well as by encouraging partners and allies to include this policy as part of their policy agendas. The grant runs through November 2014 and CSS will be focusing its efforts, now that legislation has passed, on creating awareness and implementation of the new law.
NewPublicHealth recently spoke with Nancy Rankin, vice president for policy, research and advocacy at CSS about the new law and its impact.
NewPublicHealth: Key components of the legislation you advocated for passed. What’s next in your efforts on paid sick leave?
Nancy Rankin: We are continuing to work on this issue because we recognize that having a law pass is not the end of the story. We now need to do outreach to inform workers about their new rights and employers about their new requirements, because a new law requires compliance and it requires people to be aware of its provisions.
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.
A conference in St. Paul, Minn., earlier this month examined ideas and emerging examples for building a healthier Minnesota by promoting the integration of health-related programs and community development to address health where we live, learn, work and play. The conference was convened by the Federal Reserve Bank of Minnesota and Wilder Research, the research arm of the Amherst H. Wilder Foundation. The gathering, which was a follow-up to an initial conference on the intersection of health and community development held in Minnesota a year ago, highlighted current successful cross-sector efforts throughout the state.
Elaine Arkin, manager of the Robert Wood Johnson Foundation Commission to Build a Healthier America, was a keynote speaker at the conference. Her remarks included the announcement that the Commission’s recommendations on early childhood and supporting healthy communities will be released in early 2013.
The highlighted projects included a task force on increasing access to healthier foods, often an obstacle in poorer communities; locating needed services alongside senior housing; a stable housing concept for people at risk of homelessness following a hospital stay; and a project underway to give kids living in trailer parks a safe place to play.
“The strategy that we used this year in engaging people with actual examples...was very effective in really acknowledging that this work is messy, that it does take time and that in order to keep people enthusiastic about it sometimes it does require giving people a pat on the back even just for the small progress that they’ve made,” said Ela Rausch, community development project manager of the Federal Reserve of Minnesota.
Following the conference, NewPublicHealth spoke with Ela Rausch and Paul Mattessich, PhD, Executive Director of Wilder Research.
NewPublicHealth: What were the key goals of this year’s meeting?
Paul Mattessich: The overarching goal is at the national level to bring together public health with community development finance in order to better address health issues, social determinants of health and improved community health. But what we did the first time a year ago was to try to get the two sectors to understand what each other does, what their vocabulary was, how best to work together and to start some networking.
This year the goal was to take the next step and highlight some examples where this cross-sector collaboration occurred, and to use that to try to further that even more and to underscore the fact that the two sectors really do address the same end goal, even though they do it in different ways. And if they team up they can do it more effectively.
During a town hall meeting in Minnesota last month, the Target Corporation, one of the largest employers in the United States, announced that the company will remove the criminal history question from its initial employment application. While Target has already removed this question in states where it is legally prohibited, this announcement will apply to all U.S. Target locations, even in areas where asking the question is permitted by state or local law. In Minnesota, the Ban the Box law will go into effect January 1, 2014.
“Over the past year, members of the Target team have had many productive conversations with TakeAction Minnesota,” says Molly Snyder, a spokesman for the company. “Many of our discussions have focused on Minnesota’s racial jobs gap and the barriers individuals with criminal records face when seeking employment.”
The decision by Target is in part the result of efforts led by the TakeAction Minnesota Education Fund, a Robert Wood Johnson Foundation (RWJF) Roadmaps to Health community grantee, to address job discrimination based on criminal background. Often tied to significant unemployment throughout the country, studies show that having a criminal record is a barrier to employment opportunities and depresses wages. And data from Minnesota finds that half of all former offenders are unemployed, with the rate higher for ex-offenders of color who disproportionately make up the prison population.
The Roadmaps to Health Community Grants are collaborations that have received two year funding of up to $200,000 to work with diverse coalitions of policy-makers, business, education, health care, public health, and community organizations. The grantees and their partners are pursuing policies or system changes that address the social, economic, and environmental factors that influence how healthy people are and how long they live. The Roadmaps to Health Community Grants project is a major component of the County Health Rankings & Roadmaps program—a collaboration of RWJF and the University of Wisconsin Population Health Institute.
TakeAction Minnesota is using its grant to promote new statewide fair hiring standards for businesses, such as persuading prospective employers to consider criminal records only when they directly relate to the position rather than asking questions on applications that promote blanket rejections. Earlier this year, the Minnesota legislature passed the “ban the box” legislation and it was signed into law in May, making Minnesota the third state in the nation to adopt “ban the box” in both the public and private sectors. Under the new law, an employer will no longer be allowed to include a check box about criminal background on the initial employment application.
NewPublicHealth recently spoke with Justin Terrell, manager of the Justice 4 All program at TakeAction Minnesota, about the intersection of employment and health.
NewPublicHealth: What are the ways in which employment impacts health?
Ending Healthcare Waste, Improving Healthy Lives: Q&A with the L.A. Department of Public Health’s Jonathan Fielding
In a report released last year, the Institute of Medicine found that the United States wastes billions of dollars each year on such unnecessary spending as inefficiently delivered services, excess administrative costs, fraud and missed prevention opportunities. In response, a group of senior public health scholars at the UCLA Fielding School of Public Health, led by Jonathan Fielding, MD, MPH, a professor at the school and the director of the Los Angeles Department of Public Health, published an article in the American Journal of Preventive Medicine on the improvements to population health the country might realize if only the wasted money was devoted instead to the social and environmental determinants of health. If the government could reap 45 percent of the wasted medical care costs, argues Fielding and his co-authors, and invested those resources in sectors such as education, jobs, healthier foods and transportation infrastructure, the health of millions could be markedly improved and society would see additional social benefits.
Jim Marks, Senior Vice President and Director, Health Group at the Robert Wood Johnson Foundation echoed this approach at the recent American Public Health Association (APHA) annual meeting in Boston.
"We know lots about the cost of illness, but very little about the value of health,” he said.
Marks also said that focusing on health as the ultimate goal tends to eclipse some of the social determinants that can have enormous impact on people’s lives. “Most people don’t want good health as their outcome, they want a quality life. They want to travel, take care of grandkids, have a rich family and social life—you can only do that if you’re healthy,” said Marks. “It’s unrelated to good quality medical care. It’s related to education, safe neighborhoods, [and other social factors].”
According to Marks, improving public health isn’t about curing individual diseases or fixing specific injuries. Rather, it’s about everything; the diseases are the end result of the system we live in. And with all the data we have available, we know it’s a system that needs fixing, said Marks.
Marks’ thoughts came at an APHA panel Fielding moderated in a closing day session about the health impact of investment in major social and environmental policies and interventions; information gaps and how they can be filled; and how the discussion of health spending can be re-framed so that U.S. resources can be invested most productively.
NewPublicHealth spoke with Fielding about better uses for the wasted health care spending just before the start of the APHA meeting.
Tobacco featured prominently as a public health issue at the American Public Health Association (APHA) meeting this week, including a regulatory update from Mitch Zeller, JD, who became director of the U.S. Food and Drug Administration’s (FDA) Center for Tobacco Products earlier this year. Zeller previously worked on tobacco issues in government as associate commissioner and director of FDA’s first Office of Tobacco Programs, and also as a U.S. delegate to the World Health Organization (WHO) Working Group for the Framework Convention on Tobacco Control.
NewPublicHealth spoke with Zeller ahead of the APHA meeting.
Mitch Zeller: I think most broadly my goals are to help give the center and the agency the greatest chance of fulfilling the public health mission behind the law passed in 2009 giving the Food and Drug Administration authority over tobacco. This really is an important piece of legislation. It’s really stunning that in 2013—with everything that we know about the harms associated with tobacco use—that it remains the leading cause of preventable death and disease both in this country and globally.
There are some very powerful tools that Congress has given FDA to use wisely and supported by evidence. That’s where I think, the greatest opportunity lies: to use the tools relying on regulatory science to try to protect consumers and reduce the death and disease toll from tobacco.
There are two areas where I think these tools can make a profound positive impact on public health. The first is something called product standards, which is basically the power to ban, restrict or limit the allowable levels of ingredients in tobacco or tobacco smoke. We are exploring potential product standards in three areas: toxicity, addiction and appeal. And we are funding research in all three areas and working very hard behind the scenes to find out what our options are for potential product standards in those three areas.
Stakeholder Health, formerly known as the Health Systems Learning Group, is a learning collaborative made up of 43 organizations, including 36 nonprofit health systems, that have met for close to two years to share innovative practices aimed at improving health and economic viability of communities.
The idea for the learning collaborative came from a series of meetings at the White House Office and U.S. Department of Health & Human Services Centers for Faith-Based & Neighborhood Partnerships. The Stakeholder Health administrative team is based at Methodist Le Bonheur Healthcare Center for Excellence in Faith and Health in Memphis, Tenn., and at Wake Forest Baptist Health System in Winston-Salem, N.C. The Robert Wood Johnson Foundation provided a grant to share the group’s findings and lessons learned.
Earlier this year, Stakeholder Health released a monograph to help identify proven community health practices and partnerships. Kimberlydawn Wisdom, MD, MS, Senior Vice President of Community Health & Equity and Chief Wellness Officer at the Henry Ford Health System was a key contributor to the monograph.
NewPublicHealth recently spoke to Wisdom about Stakeholder Health’s objectives, goals and emerging successes, which she also presented on at the American Public Health Association’s annual meeting in Boston.
NewPublicHealth: What are examples of implementation of the Stakeholder Health recommendations at the Henry Ford Health System?
Kimberlydawn Wisdom: There are several. Stakeholder Health talks quite a bit about transformative partnerships and the importance of those transformative partnerships. And we have some stellar examples here in southeast Michigan of transformative partnerships, and one that I’d like to point to in particular is an effort we established called Sew Up the Safety Net, which addresses decreasing the infant mortality rate in our region, which is appallingly high.
We’ve developed a partnership with three other competing health systems within the Detroit region. So while on one level we are very strong competitors, on another level, we’ve actually joined our strategies and resources together in order to address the infant mortality challenge that we have in our communities. We also have private partners and public partners that are involved with us at various levels, but I think having that unprecedented partnership with competing health systems and getting real work done is something that we’re very proud of and work very hard to maintain.
New research presented at the American Public Health Association (APHA) annual meeting in Boston today finds that when public health funding increases in a community, its rates of infant mortality and deaths due to preventable diseases decrease over time, with low-income communities experiencing the largest health and economic gains.
According to the research, conducted by Glen Mays, PhD, MPH, director of the University of Kentucky’s National Coordinating Center for Public Health Services and Systems Research, each ten percent increase in public health spending over 17 years led to a 4.3 percent reduction in infant mortality, as well as reductions of 0.5 to 3.9 percent in non-infant deaths from cardiovascular disease, diabetes, cancer and influenza.
However, these health gains were 20-44 percent larger when funding was targeted to lower-income communities. Increases in public health spending also correlated with lower medical care costs per person, especially in low-income areas. The study, which analyzed data compiled by the National Association of County and City Health Officials from 3,000 local public health agencies over a 17-year period, also found that lower death rates and health care costs were seen especially in communities that allocated their public health funding across a broader mix of preventive services.
“The results clearly show that better health and lower health care costs are possible if we simply change how and where we allocate public health funding, even if new money isn’t available, said Mays. “And it also shows that new resources, such as funding from the Affordable Care Act’s Prevention Fund, can have a larger impact if targeted to lower-resource, higher-need communities and if spread across a range of prevention strategies.”
>>NewPublicHealth will be on the ground throughout the APHA conference speaking to public health leaders and presenters, hearing from attendees on the ground and providing updates from sessions, with a focus on how we can build a culture of health. Follow the coverage here.
NewPublicHealth spoke with Mays about the new study just before the APHA annual meeting began.
NewPublicHealth: What are the key findings of the study?
Glen Mays: We’ve done prior studies that show communities that invest more on public health realize gains in health status and, over time, those communities see slower growth in medical care costs. So the goal of the study is to look at who benefits most from investments in public health.
What we found was that, not all that surprisingly, communities that are more economically constrained, that have lower income communities with higher poverty rates and lower socioeconomic status, tend to benefit the most from investments in public health activities over time. These low-resource communities see larger reductions in their preventable mortality, and they also see larger reductions in their medical care costs over time from investments in public health spending compared to more affluent communities. We expected to find that, but this is the first time we’ve been able to document the size of that effect. Those communities see about twenty percent higher rates of health and economic gain from their spending compared to more affluent communities.
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.