Category Archives: Faces of Public Health
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.
CDC’s ‘Tips From Former Smokers’ Campaign Helped 200,000 Quit
The U.S. Centers for Disease Control and Prevention’s (CDC) three-month “Tips From Former Smokers” national ad campaign helped more than 200,000 Americans quit smoking immediately, with an estimated 100,000 expected to quit permanently, according to a new CDC study in The Lancet. About 1.6 million smokers attempted to quit because of the campaign, which featured powerful—and real—stories of former smokers living with smoking-related diseases and disabilities, which encouraging people to call the toll-free 1-800-QUIT-NOW. The results far exceeded CDC’s initial goals. “Quitting can be hard and I congratulate and celebrate with former smokers—this is the most important step you can take to a longer, healthier life,” said CDC Director Tom Frieden, MD, MPH. “I encourage anyone who tried to quit to keep trying—it may take several attempts to succeed.’’ Read more on tobacco.
White House Honors ‘Champions of Change’ in Public Health, Prevention
The White House this week is honoring eight “Champions of Change” in the world of prevention and public health. The weekly event is meant to highlight and honor Americans who “are doing extraordinary things in their communities to out-innovate, out-educate, and out-build the rest of the world.” This week focuses on people who are working in the field of public health on everything from childhood obesity to reducing health disparities to fighting healthcare-acquired infections. “These leaders are taking innovative approaches to improve the health of people in their communities—and showing real results,” said Jeffrey Levi, PhD, executive director of Trust for America’s Health. “Prevention is one of the most common-sense ways we can save lives and reduce healthcare costs, and the efforts of these champions show how to put prevention to work in effective ways.” Read more on faces of public health.
Small Changes to Kids’ Routines Can Reduce Childhood Obesity
Small changes in the home environment, such as limiting the time spent in front of the television and increasing the time spent sleeping, can help reduce childhood obesity, according to a new study in the journal Pediatrics. The simple routine changes led to a slower rate of weight gain in children ages 2 to 5 (the children obviously still gaining weight overall because they were growing). After six months on the new routine, participants saw their body mass index (BMI) drop, for a healthier rate of weight gain. About 17 percent of U.S. youth are obese, with lower-income kids at highest risk, according to the U.S. Centers for Disease Control and Prevention. Thomas Robinson, MD, a professor of pediatrics and medicine at Stanford University and Lucile Packard Children's Hospital at Stanford, who was not involved in the study, said the findings were significant for the fight against childhood obesity. "These behaviors and BMI have not been easy to change in a world where junk food and screen time are so heavily marketed, and families are dealing with tremendous financial and social challenges," he said. "I think it is exciting to see studies like this one showing positive results." Read more on obesity.
In the last decade or so, leaders in the field of architecture have begun to look at not just the aesthetics of building and community design, but also their own impact on the health of communities. In New York City, for example, the local chapter of the American Institute of Architecture’s New York chapter partnered with several agencies in New York City, including the departments of Health and Mental Hygiene, Design and Construction, Transportation, City Planning, and Office of Management and Budget, as well as research architects and city planners to create the city’s Active Design Guidelines. These provide architects and urban designers with a manual of strategies for creating healthier buildings, streets, and urban spaces, based on the latest academic research and best practices in the field. The Guidelines include:
- Urban design strategies for creating neighborhoods, streets, and outdoor spaces that encourage walking, bicycling, and active transportation and recreation.
- Building design strategies for promoting active living where we work and live and play, through the placement and design of stairs, elevators, and indoor and outdoor spaces.
NewPublicHealth recently spoke with Rick Bell, policy director of AIA New York, who was instrumental in the creation of the guidelines, about the burgeoning intersection between design and healthier communities.
>>Read more on architecture and design for a fit nation.
NewPublicHealth: How did AIA New York become involved in healthy design with the city of New York?
This week’s International Making Cities Livable Conference brings together city officials, practitioners and scholars in architecture, urban design, planning, urban affairs, health, social sciences and the arts from around the world to share experience and ideas. We spoke with some of those diverse attendees to find out: what do they want the public health community to know about working across sectors to make communities healthier and more livable?
Alain Miguelez, City of Ottawa, Program Manager for Zoning, Neighbourhoods and Intensification
NewPublicHealth: What do you want public health to know about making communities more livable?
Miguelez: I want public health to know they’re at the heart of what we do. Usually urban planning is a pretty arcane thing. We’ve done a good job of making it tough for people to understand and relate to. They don’t have the patience. Public health brings it home. As we heard in a session this week, it’s not necessarily people who are disabled—it's the built environment that’s disabling.
It comes down to how you see yourself functioning in your daily life. We've made it impossible to function any way other than with a car. For some people that’s okay, but for those who’ve had a taste of something different, there’s no going back. As planners people don't trust us anymore. We’ve done a lot of things in the name of progress. We’ve disconnected people from the built environment and forced them into places that make people fat and depressed and disconnected and not well-functioning. People coo about Portland and its trams and light rail and walkability. That’s how cities are supposed to be. Everywhere else has got to come up to that standard.
When you see statistics on obesity or depression, it becomes critical, especially with kids. I have two kids and I see very clearly how the environment we build around us impacts how they grow up. It gives kids the tools to function as independent human beings. The right type of city building and suburban repair [with an eye toward public health] can do that.
During opening remarks at this year’s Keeneland Conference, hosted by the National Coordinating Center for Public Health Systems and Services Research (PHSSR) based at the University of Kentucky in Lexington, Professor Douglas Scutchfield, director of the Center, proudly announced that three of the first health departments to be accredited by the Public Health Accreditation Board (PHAB) earlier this year were in Kentucky. Accreditation had its own track during the conference scientific sessions, including a presentation from Jessica Kronstadt, MPP, PHAB’s director of research and evaluation.
NewPublicHealth caught up with Kronstadt to talk about her presentation on some very early findings from an internal evaluation of the accreditation process.
>>Read more on national public health department accreditation.
NewPublicHealth: What information is PHAB seeking to gain from an evaluation of the accreditation process?
Jessica Kronstadt: Just as we’re asking health departments to engage in quality improvement, PHAB is very much committed to engaging in quality improvement of the accreditation program. So these evaluation efforts will really help us understand what is working well in our accreditation program, and what the experience was like from the perspective of the health departments and the site visitors. This evaluation will allow us to continue to improve the accreditation process.
The American Public Health Association (APHA) is currently accepting applications through April 8 for the association’s one-year Public Health Fellowship in Government. Fellows work in a congressional office on legislative and policy health issues. The position gives Fellows the opportunity to learn about the legislative process in Washington, DC, which can be a critical skill once they return to their positions in public health, since policies are an important tool that can be used to protect Americans and their communities from preventable, serious health threats. And it also allows Fellows to provide critical input, drawing on their knowledge and experience, on the decisions that impact public health at the national policy level.
To get some background on the role of a Fellow and the impact that public health practitioners can have when working in the national policy arena, NewPublicHealth recently spoke with Fern Goodhart, current legislative assistant to Senator Tom Udall (D-New Mexico), who spent the tenure of her fellowship working in the office of Senator Robert Menendez (D-New Jersey). Ms. Goodhart was the first person awarded the APHA policy fellowship and served in 2007-2008.
NewPublicHealth: What was your background before you took the fellowship?
Fern Goodhart: I have worked in public health for 30 years including at a state health department; as director of health education at an ambulatory center; as a medical school instructor; as a member of an autonomous board of health; and as a member of my city council. So I’ve had the opportunity to see how policy was made on the local level and the state level. What brought me to the APHA Fellowship was the desire to see firsthand how policy was made at the federal level.
NPH: What kind of work did that involve?
Today, New York State Health Commissioner Nirav R. Shah, MD, MPH, released the 2013-17 Prevention Agenda: New York State’s Health Improvement Plan—a statewide, five-year plan to improve the health and quality of life for everyone who lives in New York State. The plan is a blueprint for local community action to improve health and address health disparities, and is the result of a collaboration with 140 organizations, including hospitals, local health departments, health providers, health plans, employers and schools that identified key priorities.
Dr. Shah, the architect behind today’s prevention agenda, was confirmed as New York State’s youngest Commissioner of Health two years ago. The state’s governor, Andrew Cuomo, had three critical goals: reduce the state’s annual Medicaid growth rate of 13 percent, increase access to care and improve health care outcomes.
Shah, a former Robert Wood Johnson Foundation Physician Faculty Scholar and Clinical Scholar, has already made important inroads in all three goals and the prevention agenda builds on that. NewPublicHealth spoke with Dr. Shah about prevention efforts already underway in the state, and what it takes to partner health and health care to achieve needed changes in population health.
NewPublicHealth: How does improving the social determinants of health help you achieve your goals in New York State?
Dr. Shah: New York’s Medicaid program covers 40 percent of the health care dollars spent in the state. We were growing at an unsustainable rate, and we needed a rapid, but effective solution. So, we engaged the health care community, including advocates, physician representatives, the legislature, unions, management, and launched a process that enables continuous, incremental, but real change toward the Triple Aim—improved individual health care, improved population health and lower costs.
Collectively, these efforts resulted in a $4 billion savings last year in the State’s Medicaid program, increased the Medicaid rolls by 154,000 people, and resulted in demonstrable improvements in quality throughout the system.
NPH: What opportunities do you see for public health and health care to work together in New York State?