Category Archives: Q&A
NewPublicHealth is on the ground at the NACo 2014 Healthy Counties Initiative Forum. The theme of the forum this year is “Improving Health in a Climate of Change.” Ahead of the meeting we spoke with James McDonough, county commissioner in Ramsey, Minn., and chair of the Healthy Counties initiative about the meeting and the health changes he is seeing at the county level.
NewPublicHealth: Can you tell us how the NACo Healthy Counties Initiative got its start?
James McDonough: Three years ago the president of NACo at that time, Lenny Eliason, from Athens County, Ohio, really was concerned about how the majority of health care dollars were being spent on treating preventable conditions and the whole issue of the wellbeing of our constituents and our employees. So he elevated the issue of wellness and health in counties as a presidential initiative. Typically those are short term and last for a year or two, but NACo has embraced this and has continued this on as a task force to really embed it in the work that we do—elevating how counties can have an impact on wellness in communities.
NPH: What are the current goals?
McDonough: To really elevate and get the county commissioners and county managers throughout the country to just pause and take a look at what they're doing and what they could be doing. We’ve been talking about how we can do a better job supporting counties that are already doing great work in this area and helping share those best practices, and then helping counties that haven’t really taken a look at what their role is. That can help us have a better impact on getting ahead of some of the major preventable diseases in our communities.
NPH: How important is county-level action when it comes to health?
McDonough: For the most part, counties really are responsible for the public health departments within their communities. Throughout the country we operate almost 1,000 county hospitals and close to 700 county nursing homes, so we have a lot of responsibility for public health and—just as important—we employ more than 30 million people throughout the country.
Action, responsibility and efforts vary county to county, but for example, in Ramsey County, Minnesota, where I’m the County Commissioner, we run the public health department working with our cities, the state and with the federal government. So for us it’s a really big opportunity to be the convener as well to lead the Healthy Cities Initiatives as well to a larger regional more focused and concentrated effort.
NPH: The focus of the forum includes some critical topics such as behavioral health and key health issues in jails. How much of a financial burden do these health issues place on counties?
While it has been decades since polio was a critical threat for much of the developed world, the disease—a virus that can spread from person to person and affect the brain and spinal cord with the potential for paralysis—still causes disease and death in the developing world. Earlier this year cases were reported in Syria, while in Israel the polio virus was found in soil likely from human waste infected with the disease, prompting a revaccination campaign among children age 5 and under. Polio has continued to spread in Afghanistan, Nigeria and Pakistan, and has been reintroduced and continues to spread in Chad and in the Horn of Africa after the spread of the virus was previously stopped. Other countries have seen small numbers of cases recently after no cases for decades.
Because even a small spread of the disease could reach the United States if infected individuals carry the virus here, the U.S. Centers for Disease Control and Prevention (CDC) several years ago made polio one focus of their Emergency Operations Center. CDC staff work with the World Health Organization and foreign health departments on vaccination campaigns aimed at fully eradicating the disease.
>>Bonus Content: View the CDC's infographic, "The Time to Eradicate Polio is Now."
NewPublicHealth spoke recently with Sona Bari, senior communications officer at the World Health Organization about the efforts underway to eradicate polio globally.
NPH: How are you able to detect polio outbreaks?
Sona Bari: We have a global surveillance system for polio and know from it that since 1988 the reduction of the disease has been over 99 percent. Polio is now endemic, which means indigenous polio virus transmission has never been stopped in parts of three countries: Nigeria, Afghanistan and Pakistan. So the surveillance is important because you can get polio down to very low levels like you do now, but it can reemerge. To completely eradicate polio you have to have an effective intervention, which is largely by vaccination. And you can be bring polio under very tight control by massive vaccination, but the virus is very good at finding children who are unvaccinated or under-vaccinated, and in Nigeria, Afghanistan and Pakistan we still have large groups of unvaccinated children. So the reason that polio transmission has not been stopped in these areas is that not enough children are vaccinated.
NPH: Why is there insufficient vaccination in those countries?
Bari: The basic reason is the quality of vaccination activities. Do these countries have decent health systems—strong routine immunization systems where children are regularly taken to a medical facility for their immunizations? When there are mass vaccination campaigns, are we reaching all children? Then there are, on top of that, layers of political complexities. In one part of Pakistan, for example, there is a ban on polio vaccinations by the local warlords. So there are access and security issues, layered on top of the difficultly of reaching all who need vaccines in countries such as Nigeria or Pakistan. That said, we know that these circumstances are not unique. They may differ from country to country, and each country does have a unique combination of the obstacles, but polio has been eradicated in countries that are far poorer than Nigeria or Pakistan, that have had worse conflict and that have perhaps much worse health systems. So it can be done.
A new report from Trust for America’s Health finds that despite recommendations by medical experts about the effectiveness and safety of vaccines, an estimated 45,000 adults and 1,000 children die from vaccine-preventable diseases each year in the United States.
NewPublicHealth spoke with Litjen (L.J) Tan, MS, PhD, chief strategy officer of the Immunization Action Coalition, to ask about ongoing efforts to improve immunization rates among all age groups across the nation. The Coalition works to increase immunization rates and prevent disease by creating and distributing educational materials for health professionals and the public and facilitates communication about the safety, efficacy, and use of vaccines within the broad immunization community of patients, parents, health care organizations, and government health agencies. The Coalition is supported by the U.S. Department of Health and Human Services.
NewPublicHealth: What are the critical gaps in immunization in the United States—for children and adults?
Litjen Tan: Immunization rates are really high in our childhood population, but generally not at all high in the adult population, though for some vaccines the rates are improving. We are also not doing very well for adolescents. On the broader level I think what the immunization rates reflect is the state of preventive care in the United States when you come out of childhood, which is why I think the Affordable Care Act really is a great boon. We’ve got this wonderful preventive care model for our kids; we take our kids in, we get them their shots, they get protected and we’ve got high coverage rates generally over 90 percent for all major vaccines. We have almost no vaccine-preventable disease in the United States except for instances linked to pockets of populations that haven’t been vaccinated—as we’ve seen recently with measles.
But then we get to adolescence we have this breakdown. Rates for HPV vaccination are not so good. Our meningococcal vaccination rates are not where they should be and neither are the tetanus, diphtheria and pertussis booster rates in adolescents. What happens with the adolescents is parents don’t necessarily bring them in for prevention checkups anymore. We bring them in when there’s a problem or when they need a school sports visit, and so we plant in adolescents this idea that care is no longer about prevention but care is now about acute care, and that persists into adulthood. This is the thinking that stops us from saying, “hey, do I need my vaccines? When should I get them?”
We need to make sure that our adolescents get the idea that vaccines prevent disease and that they actually do have vaccines that are recommended for them and then I think we’ll begin to see an appreciation of immunizations for adults as well.
NPH: Do we need to target both parents and the adolescents themselves?
Tan: Absolutely, but there’s a lot of discussion about how we do that. It gets a little tricky because we push autonomy of the adolescent, and we have a precedent in public health—discussions between providers and adolescents about sexually transmitted infections—but there are a lot of legislative and regulatory barriers against directly talking to an adolescent in the absence of a parent.
Fifteen Years after Tobacco Settlement, States Falling Short in Funding Tobacco Prevention: Q&A with Danny McGoldrick
On November 23, 1998, 46 states settled their lawsuits against the nation’s major tobacco companies to recover tobacco-related health care costs, joining four states—Mississippi, Texas, Florida and Minnesota—that had reached earlier, individual settlements.
These settlements require the tobacco companies to make annual payments to the states in perpetuity, with total payments estimated at $246 billion over the first 25 years.
Yesterday a coalition of health advocacy groups released the latest edition of A Broken Promise to Our Kids, an annual report on state use of tobacco funds for tobacco prevention and cessation efforts. As in years past, the report finds that most states fall short in the amount of money they allocate to prevent kids from smoking and to help current smokers quit.
The groups that jointly issued the report include the Campaign for Tobacco-Free Kids, the American Heart Association, American Cancer Society Cancer Action Network, the American Lung Association, the Robert Wood Johnson Foundation and Americans for Nonsmokers’ Rights.
Key findings of the 2013 report include:
- Over the past 15 years, states have spent just 2.3 percent of their total tobacco-generated revenue on tobacco prevention and cessation programs.
- The states this year will collect $25 billion from the tobacco settlement and tobacco taxes, but will spend just 1.9 percent of it—$481.2 million—on tobacco prevention programs. This means the states are spending less than two cents of every dollar in tobacco revenue to fight tobacco use.
- States are falling short of the U.S. Centers for Disease Control and Prevention’s (CDC) recommended funding levels for tobacco prevention programs. Altogether, the states have budgeted just 13 percent of the $3.7 billion the CDC recommends.
- Only two states—Alaska and North Dakota—currently fund tobacco prevention programs at the CDC-recommended level.
To discuss the ramifications of the latest edition of the Broken Promises report, NewPublicHealth recently spoke with Danny McGoldrick, vice president of research at the Campaign for Tobacco-Free Kids.
NewPublicHealth: Can you give us some background on the Tobacco Master Settlement Agreement?
Danny McGoldrick: This is the 15th anniversary of the Tobacco Master Settlement Agreement, when 46 states and the District of Columbia settled their lawsuits against the tobacco companies mostly to recover the costs that they’d incurred treating smoking-caused disease in their states. Four other states had settled individually with the tobacco companies prior to the Master Settlement Agreement, and so this provided for some restrictions on tobacco company marketing; they promised never to market to kids again, which is ironic, but it also resulted in the tobacco companies sending about $250 billion over just the first 25 years of the settlement for the states to spend as they saw fit. They left that to the province of the state legislators and governors to decide how those funds should be spent.
NewPublicHealth Q&A: John Auerbach and Cheryl Bartlett on the Massachusetts Prevention and Wellness Trust
The Massachusetts Prevention and Wellness Trust is a four-year, $60 million project designed to support prevention and health-promotion activities in the state. The first project of its kind in the United States will fund six to 12 collaborative initiatives, and partners on the initiative will include municipalities, community-based organizations, health care providers, regional agencies and health plans. Information on the Trust is detailed in a new report prepared by the Institute on Urban Health Research and Practice at Northeastern University and funded by the Robert Wood Johnson Foundation.
The vision behind the creation of the project is to give all Massachusetts residents the opportunity to live in communities that promote health, as well as seamless access to all community and clinical services needed to prevent and control chronic diseases. It was created because while there is access to health insurance and health care in Massachusetts, health costs continue to rise. The goals of the project include:
- Reducing the rate of the state’s most costly preventable health conditions
- Reducing health disparities
- Increasing healthy behaviors
- Increasing the adoption of workplace wellness programs
- Developing a strong evidence base of effective prevention programs
In order to implement these goals, the Massachusetts Department of Public Health identified four priority areas: tobacco use, childhood asthma, hypertension and elder falls prevention—all of which should be considered closely when working to reduce health disparities and co-occurring mental health conditions in these areas.
A new infographic created for the Prevention and Wellness Trust’s inauguration perfectly illustrates how community links work together to improve health under the principles of the Trust. For example, a diagnosis of hypertension would need a provider to prescribe medications, but the obesity and exercise needs that would also improve the condition for many patients requires input from other community entities, including:
- Classes in exercise, medication and stress reduction by community agencies
- Chronic disease self management classes and home visits for medication use instruction by a community agency
- A neighborhood policy that provides support for transportation changes to encourage walking or biking and zoning for healthy food stores
- A neighborhood policy that provides support for more accessible recreation options in parks and city centers for increased stress reduction
- Workplace policies that provide support for workplace wellness programs that help provide and encourage exercise, healthy foods and stress reduction
NewPublicHealth recently spoke with John Auerbach, a Professor at Northeastern University and the primary author of a report on the Trust, and Cheryl Bartlett, public health commissioner of Massachusetts and the lead person charged with its implementation.
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?