Archive for November, 2009

A Study of Mass Incarceration in the Bronx

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Bronx County Hall of JusticeThe most recent issue of the Journal of Health Care for the Poor and Underserved includes an article we wrote on the impact of mass incarceration on the communities we serve in the Bronx:

Shah M, Edmonds-Myles S, Anderson M, Shapiro ME, Chu C. The Impact of Mass Incarceration on Outpatients in the Bronx: A Card Study. Journal of Health Care for the Poor and Underserved, Volume 20, Number 4, November 2009, pp. 1049-1059.

Here is the abstract of the article.

Objective. We examined the impact of arrest and incarceration on primary care patients in the Bronx, New York.

Methods. Patients at three clinics were asked eight questions concerning current and past involvement in criminal proceedings, arrest, and incarceration.

Results. One hundred eighteen patients were surveyed. Eleven (9%) patients were currently involved in criminal proceedings. Twenty-one (18%) currently had a family member in jail or prison. Twenty-nine (25%) reported ever being arrested; 65 (55%) reported that they or a family member had been arrested. Twenty-one (18%) had been incarcerated; 60 (51%) reported they or a family member had spent time in jail or prison. For most variables, rates were higher for men and the adults accompanying children at pediatric visits. Clinicians reported positive experiences discussing incarceration.

Conclusions. Involvement with the criminal justice system was common among our patients. Discussion of incarceration did not appear to have a negative impact on the clinical relationship.

The United States incarcerates far more people than any other country in the world.  Last year, the Pew Charitable Trusts estimated that 1 out of every 100 American adults was behind bars.  The impact of this policy falls primarily on men, on minorities and on the working class.  The term mass incarceration was coined to describe how police targeting of specific neighborhoods (urban, minority, working class) creates communities where a large percentage of the men are in prison or jail.  Taken as a whole the Bronx has high rates of arrests and incarceration, although even within the Bronx some neighborhoods are affected more than others.  This is well illustrated in a series of maps produced by the Justice Mapping Center.

In our clinical work we have come to appreciate how incarceration affects not just the person imprisoned, but also their family.  Ailing grandmothers end up caring for children when Dad goes to jail and Mom has to find a job. Children grow up in a single family home while their spends years in jail.  Young boys who are having difficulty in school start playing hooky, get involved with petty crimes, end up incarcerated, and are then socialized by the prison gangs into more severe criminal activity.  And just as families are affected by incarceration, so too are their communities.

In this study we tried to assess how common arrest and incarceration were in our patient population.  Over the course of a few weeks in the fall of 2008, our clinicians asked patients a few simple questions about incarceration in the course of their clinic sessions. The data was collected in such a way as to protect the anonymity of the respondents.  In all we collected data from 118 patients at three clinics.  We found that 11 patients (9%) were involved in some type of criminal proceedings at the time of the visit.  Twenty-nine (25%) reported that they had been arrested at some time in their life and twenty-one (18%) told us they had spent time in prison.   Twelve percent of the families had someone return from jail within the past year.  What was particularly concerning to us was that involvement in incarceration and arrest was more common among the adults bringing their children in for care than it was among the adults presenting for themselves.

The card study also brought to light issues that had previously been hidden.  One of our residents remarked:

The card study of incarceration brought on an interesting discussion with a patient of mine whose son was imprisoned for many years. She’s a patient I’ve seen several times in clinic but with whom I had never thought to broach this topic.

This data reinforces our sense that mass incarceration has a major negative impact on the families and communities we serve.  It suggested to us that knowing about an incarceration or arrest history may help doctors better care for their patients.  This also seems to be an area in which doctors can advocate for system-level changes – such as reform of punitive drugs laws, expansion of drug treatment programs, improvements in the school system – that can prevent people from landing in jail.

posted by Matt Anderson, MD

Dr. Jaime Gofin on Community Oriented Primary Care (COPC)

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38gofinOn 10/13/2009 Dr. Jaime Gofin came to Social Medicine Rounds to discuss the gap existing between the teaching and the practice of Community Oriented Primary Care (COPC).  His presentation was followed by a discussion during which three New York clinicians presented their current work in the community. Dr. Gofin then explored the relevance of  COPC to their specific projects.

Few people in the world today are better qualified to discuss COPC than Dr. Gofin.  A native of Uruguay, Dr. Gofin trained under the Karks (who originated the COPC model) and ran a Master’s Program in COPC at the Hadassah Community Health Center of the School of Public Health & Community Medicine in Jerusalem.  He is just finishing up a two year appointment at George Washington University in Washington, DC where he set up a COPC certification track within the GWU MPH Program.

What is COPC?

What is now called COPC was developed in South Africa in the 1940’s by Sidney and Emily Kark.  The second issue of our online journal Social Medicine includes a classic paper by the Karks entitled A Practice of Social Medicine which sets out the origins of their model. The Kark’s article is accompanied by an introduction written by Dr. Gofin.

During his talk, Dr. Gofin described five principles associated with COPC:

  1. Responsibility for a defined population.
  2. Care based on identified health needs at the population level.
  3. Prioritization of health needs.
  4. Implementation of an intervention program covering all stages of the health/illness continuum and impacting on the prioritized conditions.
  5. Community Involvement.

He further identified four defining features of COPC:

  1. Individual and community care/community medicine.
  2. Integration of individual care & public health.
  3. Provision of care to entire populations – healthy or sick – and based on identified health needs.
  4. Community participation and intersectorial coordination.

While Dr. Gofin was able to provide examples from around the world where COPC was implemented (see below), he recognized that in many places there was a “gap” between teaching about COPC and actually carrying it out.  Undoubtedly, there is great interest in COPC within medicine and public health. The November 2002 American Journal of Public Health devoted a special section COPC; it was also the subject of a number of sessions at the APHA 2002 annual meeting. Three years earlier Family Medicine Residency Directors had recommended the incorporation of COPC into FM residency training programs.  Yet a survey done in 2000 revealed that only 7% of doctors in these residency programs actually practiced COPC.  The disparity between interest in COPC and actual practice was highlighted by a 2008 literature review on COPC which found that 60% of the COPC literature was composed of articles on “general theory and education”; only 25% was comprised of “project reports and research.”  As noted by one analyst: “… COPC’s contribution to current health practice remains more symbolic than substantive.”

Why does such a gap exist?  Dr. Gofin cited a number of reasons: lack of infrastructure to implement and sustain COPC, lack of financing for non-clinical approaches to health, difficulties in defining the “community” (especially urban settings), skepticism that COPC can be rigorously evaluated (there are no RCT’s), fragmentation of health care services among multiple payers, lack of models for practice and lack of a supportive community.  He expressed frustration that medical schools don’t teach community medicine because there are no clinics where students can practice; yet health services can’t provide community models because they don’t have trained practitioners. He also noted that most owners of health services have a different, non-COPC agenda.

Promoting COPC: Spain, Britain, Uruguay, and the US

Dr. Gofin demonstrated, however, that in several diverse countries he had been able to overcome this gap.  He cited four programs which had been developed in very different contexts.  Beginning in 1987 he worked with Family Physicians in Spain to integrate COPC principles into community health centers. By 2005 a network of 43 health centers were working with a community orientation. He had collaborated with Primary Health Care Trusts in the British National Health Service to use COPC in GP offices. As a result COPC programs for the very elderly (those over 75) had been established in Camden and Islington. After the recent change of government in Uruguay, he had worked with the Ministry of Health to develop a COPC model in seven provincial health centers. Finally, he had established the COPC certificate program at George Washington, a program that had required developing COPC projects in Washington, DC.

At this point the floor was turned over to three clinicians each of whom presented their community work for Dr. Gofin’s commentary.

Walking in Washington Heights

Dr. Richard Younge of the Family Medicine Division at Columbia discussed a project  to encourage walking in the community. The project had started at Alianza Dominicana, a community-based organization in Washington Heights. It was recognized that women participating in their substance abuse programs did not get much exercise. A program was set up to encourage them to walk in the neighborhood on a regular basis as a group. The Family Medicine residency had gotten involved in supporting the program as the initial funding faded. Dr. Younge recognized that this project was an example of service learning and not COPC; the residents promoted it only for the women coming in for care at their clinic. Unfortunately, like many resident-based projects, there was a need for more structure, and the residency program was now looking to partner with another Community-Based Organization.  Dr. Younge noted the difficulty of trying to define a community in a setting like contemporary New York City. The Karks, he pointed out, had been able to get out a map and draw a defined area of responsibility around their health centers. This clearly would not work for us.

Bangladeshi Women in the Bronx

Dr. Alison Karasz, a clinical psychologist and researcher with our department, discussed her work with Bangladeshi women in the Bronx.  She had partnered with Dr. Jean Berg of the Jacobi Medical Center Family Medicine Program in a study of cultural differences in models of depression.   When the study was over she wanted to give something back to the community.  Her first impulse was to teach the women how to drive a car.  She recounted (with a smile) what it was like to give driving lessons around Yankee Stadium to women attired in full Purdha. This experience had given her “the bug to serve, something researchers rarely have an opportunity to do.”

She and Dr. Berg received a $50K grant from New York City Council to  develop community based activities in this community.   They were able to hire a community activist and eventually received funding from the National Institutes of Mental Health to develop a Community-Based Participatory Research (CBPR) Project on managing depression (typically conceptualized as “stress” by the women).  This money allowed for the hiring of five community health workers and the development of active discussion groups.  Dr. Karasz reviewed some of her own concerns and struggles over how to define a community, how to obtain its participation, and how to establish partnerships.  She noted (again with a smile) that many of the women in the community had a finely tuned sense of feminism and were well in touch with the structural causes of their distress.

Green Carts for New York City

Our last presenter was Dr. William Jordan, a graduate of our program and currently a Faculty Development Fellow.   He described a several year collaboration with Esperanza del Barrio, an organization of street vendors in New York City.   This collaboration had led to his election as President of the organizations’ Board of Directors and an active role as a fundraiser.  This work was closely linked to the NYC Department of Health’s Green Carts Initiative which seeks to subsidize mobile food carts selling fresh produce.  Dr. Jordan spoke about the difficulties of fund-raising and how, in his role as President of the Board of Directors, he had acquired a panel of uninsured street vendors as patients.

Dr. Gofin comments

Dr. Gofin noted that these projects highlighted the difficulties of identifying a geographically-delimited community in large cities.  He suggested that the term “population” might better define the groups we were trying to reach.  He noted that it was certainly possible to start initially with a defined group, even a small one, and then to expand it. It was important, however, that this group not just include patients. It needed to include healthy people so that the responsibility of the clinic included the entire population, not just those identified as patients. This, he emphasized, was one of the traits that made COPC different from simply good primary care.  He noted that the community-based participatory research (CBPR) model was becoming increasingly popular amongst those interested in community health, but that this was research, not service.  Finally, he noted that service learning, even service learning in the community, was also quite different from COPC.  He finished by expressing his encouragement to see so much community work going in New York  City.

posted by Matt Anderson, MD

Community Health Care in Cuba

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On September 27th 2009, Dr. Joan Beder, Dr. Susan Mason, and Joyce Wong, CSW spoke at Social Medicine Rounds on Community Health Care in Cuba. Drs. Beder and Mason have recently published a book of the same title which we have reviewed on the Portal (see: New Book on the Cuban Health Care System).

Breast Cancer in Cuba

IMG_0537Dr. Joan Beder began with a discussion of her work with breast cancer patients. Dr. Beder is a professor of social work at the Wurzweiler School of Social Work at Yeshiva University. She has an interest in oncology services and specifically services for women with breast cancer. She began her talk by pointing out some of the contradictory aspects of work in Cuba. Cubans have guaranteed rights to health and education; this something that we did not have in the US. Yet it was clear walking around Havana that Cuba is  an impoverished country where food was rationed.

Dr. Beder noted that the Cuban system provided essentially the same treatment options – chemotherapy, radiation, and surgery – that were available to patients in the US. But the supply of drugs was quite limited. Breast cancer screening programs had been impacted by the US trade embargo; the Cubans could not obtain the best mammography film and equipment because it was produced in the US. As a consequence higher than necessary doses of radiation were used in mammography.

Dr. Beder was asked by the  Cubans to provide some guidance on helping women with the psychosocial consequences of breast cancer. She worked with the Federation of Cuban Women which runs a series of Women’s Centers where breast self-examination and mammography are promoted. Initially they considered setting up a self-help hotline for breast cancer survivors. This turned out to be problematic due to the deficiencies of the Cuban system; people may not always have access to a phone in a private setting.  Her work led her to undertake a training program  in the special needs of oncology patients for Cuban social workers.

She concluded by pointing out that cancer is now the second leading cause of death in Cuba; cardiovascular disease is number one. Cognizant of this, the Ministry of Health has begun a special national program to train doctors in the prevention and early detection of cancer.

Schizophrenia and Mental Illness

Susan Mason teachingDr. Susan E. Mason is also a professor of social work at Yeshiva University; in addition she is  a professor of sociology and the chair of the college departments of sociology and political science. Her area of expertise is schizophrenia and she is the co-author of Diagnosis Schizophrenia: A Comprehensive Resource for Patients, Families, and Professionals, a fascinating book which uses patient stories to describe what it is like to have schizophrenia.

The Cuban approach to mental illness also has been shaped by a context where resources are limited and medications are in short supply; again, this is due – in part – to the effects of the embargo. Psychosocial treatments have been emphasized and mental health is based on three principles: community, prevention, integration. Arts and music programs are valued and accepted as mental health interventions. She described with a mixture of amusement and admiration how official meetings might be interrupted for a short break allowing the participants (“even the Ministers”) a chance to sing and dance. (It was later suggested that this would be a great idea for hospital rounds).

Care for mentally ill patients was often provided by social workers who live in the same community as the patient and make house calls as needed. When patients needed more supervision, family members were paid to stay at home and care for them. When a family member was not available, patients were placed in a foster home.  Since family members (or foster families) were paid, patients with mental illness were not typically viewed as an economic burden for their family or community.  Dr. Mason shared some pictures of a day program run from a private home. The atmosphere was quite domestic and she remarked: “It feels like you just want to hang out there.”

Did this model work? Dr. Mason expressed frustration that despite the theoretical advantages of this community model for psychiatric care, there was really no hard outcomes data to demonstrate that it was effective.

A Healing Environment

joyce wongJoyce Wong is a social worker at a Bronx community health center where she works primarily with South East Asian immigrants. She grew up in Washington Heights in a community that was largely Cuban and later traveled to Cuba to visit Havana’s Chinatown. This had once been one of the largest “Chinatowns” in the Western Hemisphere. With emigration, the population has dwindled considerably and now consisted primarily of the elderly.

In Chinatown, she interviewed elderly men to learn how they had managed to survive in Cuba after leaving their homes in China. She found the men relied on ethnic pride and identity, maintaining their language, and consciously suppressing painful memories. She described this not as a form of repression, but rather as a conscious decision to look for happiness and self-healing.

Ms. Wong made a short film about her trips to Cuba, a place she felt was a “healing environment.” La Magia de Cuba (Cuba’s Magic) is a montage of music and photos and is available on Picasa at this  link.


To read more about this work, please consult Drs. Mason and Beder’s book: Community health care in Cuba.

The situation of Cuban patients, denied access to the best possible care because of the US trade embargo was denounced by Amnesty International in September. Readers interested in learning about the health impacts of the embargo should consult their report: The US Embargo against Cuba: Its Impact on Economic and Social Rights.

posted by Matt Anderson, MD

"Don’t Burn It – It's Already on Fire" New York Premiere of Vietnamese Film

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Dang_Thuy_Tram_DiaryOur colleague Minh Ha, a Vietnamese social worker, passed on this information about the New York premiere of “Don’t Burn it – It’s already on fire” a Vietnamese film based on the war diary of Dang Thuy Tram, a Vietnamese physician.  Dr. Tram’s diary has been published in English under the title: Last Night I Dreamed of Peace.

Publisher’s Weekly described the book in these terms:  “In 1970, while sifting through war documents in Vietnam, Fred Whitehurst, an American lawyer serving with a military intelligence dispatch, found a diary no bigger than a pack of cigarettes, its pages handsewn together. Written between 1968 and ’70 by Tram, a young, passionate doctor who served on the front lines, it chronicled the strife she witnessed until the day she was shot by American soldiers earlier that year at age 27. Whitehurst, who was greatly moved by the diary and smuggled it out of the country, returned it to Thuy’s family in 2005; soon after, it was published as a book in Vietnam, selling nearly half a million copies within a year and a half. The diary is valuable for the perspective it offers on war—Thuy is not obsessed with military maneuvers but rather the damage, both physical and emotional, that the war is inflicting on her country. Thuy also speaks poignantly about her patients and the compassion she feels for them.”

The film will be shown from 7pm – 9.30pm on Saturday November 14th, 2009 in Room 200. Cantor Film Center, 36 East 8th Street & 5th Ave, NYC.
New York University. The director, Dang Nhat Minh, will be present for a discussion after the film.

posted by: Matt Anderson, MD

2009 Spirit of 1848 sessions at APHA

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Both for those readers who will be attending next week’s APHA (American Public Health Association) Convention and particularly for those who will not be there, we wanted to share this year’s Spirit of 1848 sessions.

Berlin Revolution, March 1848

Berlin Revolution, March 1848

The Spirit of 1848 is happy to share our final program for the 137th annual meeting of the American Public Health Association, with the theme of “Water and Public Health” (November 7-11, 2009; Philadelphia, PA). SESSIONS

All Spirit of 1848 sessions will be held in the Philadelphia Convention Center (hereafter referred to as “PCC”).

Monday, November 9, 2009
10:30 am to 12 noon:
The Social History and Politics of Water and Public Health (Session 3162.0, PCC 113A)

10:30 am
INTRODUCTION: Social history and the politics of water and public health.
Anne-Emanuelle Birn, MA, ScD

The introduction will lay out key factors in critically examining the social history and politics of water and public health, especially in relation to water access and sanitation. Examples of the politics of past political and social struggles for the right to water and sanitation in Europe and throughout the Americas will be used to set the context for the papers presented in the session.

10:35 am
Unclogging obstacles to water and sanitation coverage: the promise and perils of comparing Philadelphia’s history with the crisis in the developing world.
Niva Kramek, MES and Katryn Bowe, BA

Less than one hundred years ago, annual typhoid outbreaks in Philadelphia killed more than 400 people each summer for 30 years. Contaminated drinking water and the lack of a system for removing human and animal waste plagued the city, presenting many of the same public health challenges facing developing cities today. Using Philadelphia’s water history as a case study in conjunction with current practices in several developing locations, this paper will address essential issues confronting clean water and adequate sanitation: political disregard for water issues until moments of crisis; complex trans-boundary cooperation requiring a watershed perspective; the inability of epidemics alone to prompt action; persistent difficulties in financing these systems; and deep-rooted taboos surrounding human waste that discourage changing norms. Efforts to provide clean drinking water and wastewater treatment that is environmentally and economically sustainable benefit from understanding how contemporary challenges were addressed in the past. As the first city in the world to provide free drinking water and as an innovator in centralized water delivery methods, Philadelphia’s history provides inspiration. However, though understanding history can prevent repeating past mistakes, directly copying what once worked misses opportunities for more equitable, efficient, and sustainable development driven by the unique character of many areas, and of economic, technological, and social advances. Philadelphia’s mistakes demonstrate what to avoid, and it has much to learn from innovations in today’s developing areas, at a time when waste must be used as a resource and small scale technology and financing have become important tools.

10:55 am
Building inequality: sewers, civic ideals, and public health in Los Angeles, 1873-1891
David Torres-Rouff, PhD

Infrastructural development is a critical historical process within which to explore the relationship between water, human rights and public health. Throughout the nineteenth century, civic leaders in U.S. cities built sewer systems to enhance the purity of municipal waters and improve public health. Los Angeles’ city council began building sewers in 1873, converting miles of open water canals, or zanjas, into underground sewers over the next twenty years. While not an unusual aspect of urban development, sewer building in Los Angeles commenced following the resolution of an acrimonious, fifteen-year long battle between Mexican Californians, who advocated common ownership and equitable, cost-free distribution of the city waters, and Anglo Americans who preferred private ownership, fees for service, and the separation of waste, agricultural, and potable waters into separate pipes to improve the “purity” of the water supply. Following a decisive political victory in 1872, Anglos built a sewer system that fundamentally altered people’s relationship to water, converting it from a communal resource into a commodity. However, city leaders failed to build sewers where Mexican and Chinese Angelenos lived. In addition to exposing these neighborhoods to greater health risks, unequal sewerage created experiential asymmetries between Mexican/Chinese and Anglo American districts, provoking condemnations of Chinese and Mexican residents as dirty and diseased. Over time, these stereotypes have worked in lock step with the spatial and institutional barriers resulting from infrastructural inequality to limit marginalized populations’ claims to human rights in Los Angeles.

11:15 am
Critical reflections: on history, culture, and struggles over access to water and sanitation.
David S. Barnes, PhD (discussant)

As discussant, I will reflect critically on the presentations included in this session, emphasizing the practical value of historical perspective and attention to cultural factors in contemporary struggles over access to water and sanitation.

11:30 am
Question & answer period

Monday, November 9
2:30 pm to 4:00 pm:
Macroeconomics, Political Systems, and Population Health and Health Inequities (Session 3361.0, PCC 108B)

2:30 pm
Introduction to Politics of Public Health data session
Catherine Cubbin, PhD

2:35 pm
Health inequities in global context: evidence from the World Values Survey.
Jason Beckfield, PhD and Sigrun Olafsdottir, PhD

The existence of social inequalities in health outcomes is well established in social science research from multiple disciplines. One strand of research focuses on inequalities in health within a single country. A separate and newer strand of research focuses on the relationship between aggregate inequality and population health across countries. Despite the theorization of (presumably variable) social and political conditions as determinants of population health and health inequities, the cross-national literature has focused on population health as the central outcome. Controversies currently surround macro-structural determinants of overall population health such as income inequality, the welfare state, and economic development. We argue that these debates would be advanced by conceptualizing inequalities in health as cross-national variables that are sensitive to social conditions. Using data from the third wave of the World Values Survey, we examine cross-national variation in inequalities in health. The results reveal dramatic variation in variations in health according to income and education. We find that this variation in the socioeconomic gradient can be partially accounted for by cross-national differences in economic development, population health, and, especially, income inequality. We conclude by discussing the implications of this research.

2:55 pm
Income support and women’s health reform in developing countries: the impact of microfinance.
Deborah Viola, PhD

Health systems and pathways to better health are shaped by the economic environment and the social structures and political forces that govern each country. The objective of this study is to highlight the link between globalization and women’s health reform by specifically considering the World Trade Organization Agreement on Agriculture (AoA), the microfinance response, and their health impact on women in developing countries. Low socioeconomic status has been linked to a great burden of disease and death in developing countries. Studies have illustrated the impact of the AoA on decreased earnings and employment, poverty, and reduced access to education and health care services. These burdens further exacerbate existing gender inequalities within developing countries, since agriculture practiced by the poor is often considered “women’s work.” Several studies have explored the role of microfinance in rejuvenating urban agriculture and putting poor women “back to work.” However, researchers have rarely tested whether social programs designed to alleviate poverty or otherwise improve economic well-being for large segments of the population are linked with health improvements. Further, researchers have questioned the merits of existing quantitative analyses in capturing the impact of economic and development policies on women’s health status in developing countries. We present preliminary qualitative case studies of women and the use of microfinance to suggest that such a relationship does exist and demonstrate the need for more empirical, multidisciplinary work to be done in this area if we are to truly impact women’s global health.

3:15 pm
Public health implications of economic recession.
Jessica M. Robbins, PhD

Based on literature review and local health informants, we attempted to assess foreseeable public health effects of economic recession, with a specific interest in effects that could be addressed by local public health action. Poverty, unemployment, and financial strain are incontrovertibly associated with increased mortality and poorer health in all populations, but whether and how these effects change during recessions is unclear. Overall effects of recession on mortality are disputed, but considerable evidence suggests that at national levels cardiovascular and total mortality usually decline during recessions, while suicide may increase. Birth rates may decline, but no studies on specifically urban populations confirm this. Mental health symptoms appear to increase during recessions for the employed as well as those losing work. Increases in distress and morbidity may disproportionately affect women. Pessimism and uncertainty about the future are strongly associated with ill health. Effects on smoking and alcohol use are complex, as population-wide both usually decline during recessions, although the unemployed may be least likely to quit smoking. Negative health impacts of unemployment may be most severe at the time when job loss occurs. Early accounts suggest that, in Philadelphia, individuals are postponing or forgoing needed hospital-based medical care. More patients are using public health clinics, and more of them are uninsured. Evidence on the effects of recession for specific population groups, including vulnerable populations and different age groups, is largely unavailable. Policy implications and areas in which local public health efforts might be effective will be discussed.

3:35 pm
Nancy Krieger, PhD (discussant)

As discussant, I will reflect critically on the presentations included in this session, as framed by a discussion of the importance of analyzing political systems and priorities is essential for understanding and improving population health and rectifying health inequities.

3:45 pm
Question & answer period

Monday, November 9, 4:30 pm to 6:00 pm:
Indigenous Methodologies in Public Health Research: An Issue of Social Justice & Good Science (Session 3438.0, PCC Auditorium)

Introduction: Indigenous Methodologies in Public Health Research: An Issue of Social Justice & Good Science
Nancy Krieger PhD

In this introduction, as Chair of the Spirit of 1848 Caucus, I will briefly describe the origins, objectives, and format of our session, whose content was jointly organized by Vanessa Watts and Suzanne Christopher. This session will focus on methods for advancing discussion and practice of the use of Indigenous methodologies in public health research. Many researchers involved in research with Indigenous peoples have raised questions regarding whose perspective is informing the research process and what it means for those involved. Indigenous methodology is an approach to culturally appropriate knowledge production and dissemination. The purpose of indigenous methodologies is to ensure that research is done in a respectful, ethical manner that is valuable and useful from the view of Indigenous people. In this session, we will explore these issues in relation to the three themes of the Spirit of 1848 caucus: (1) the social history of public health, (2) the politics of public health data, and (3) progressive pedagogy, and our overall focus on links between social justice and public health.

Legacy of conventional research with Indigenous communities and its relevance to current public health research.
Suzanne Christopher, PhD and Vanessa Watts, PhD

Recent theorists and commentators have pointed out the history of deleterious effects brought about by conducting research conventionally in Indigenous communities and with Indigenous individuals. We summarize this research and explore the relevance of this history to current public health research. Much of the previous conventional research is regarded as an expression of colonialism because it has exploited, marginalized, ignored contributions, pathologized and problematized communities and individuals. Using examples from the UN Principles and Guidelines for the Protection of Indigenous Heritage and UN Declaration on the Rights of Indigenous Peoples, we will discuss rights that Indigenous people have regarding indigenous methodologies and indigenous data. We examine underlying presuppositions and values that gave rise to this conventional research. We end by providing a definition of indigenous methodologies and indigenous knowledge that can be usefully set into dialogue with mainstream public health approaches.

The politics and purposes of Indigenous public health data.
Bonnie Duran, DrPH

This presentation will provide a brief genealogy of data collection and use (a) about “Indian Country”, and (b) from “Indian Country” and will (c) review current day Tribal recommendations and regulations regarding research approvals and data sharing. The presentation will also provide a brief introduction to the “International Indigenous Health Measurement Group” and other national and international efforts to expand the sources of data and improve the collection, analysis, interpretation and dissemination of information useful for improving the health of Indigenous populations.

Teaching Indigenous research methodologies.
Felicia S. Hodge, DrPH

Teaching Indigenous research in public health research is a valuable tool to advance the trajectory of health and wellness. Use of Western teaching methods is replaced with storytelling, grounded theory, and group process. Learning how to teach, how to listen, and when and where to place the perspectives of stakeholders addresses the barriers, strengths, and value of Indigenous research methodology.

Graduate researchers in Aboriginal health & Indigenous methodologies.
Katherine Minich, MHSc and Krista Maxwell, MA, PhD(C)

This paper will explore perspectives on self-location and identity, cross-cultural collaboration and Indigenous methodologies amongst Indigenous and newcomer graduate students doing research in Aboriginal health in Canada. The Institute of Aboriginal People’s Health, established in 2000 as one of the Canadian Institutes of Health Research, has made efforts to develop Aboriginal capacity in health research through its support for national Network Environments for Aboriginal Health Research (NEAHRs). At recent annual national gatherings of graduate students doing research in Aboriginal health through the NEAHRS, close to 50% of participants have self-identified as Aboriginal. Issues of partnerships with Aboriginal communities and ethics guidelines specific to Aboriginal health research have featured prominently in discussions at these gatherings. Less attention has been given to critical reflection on researcher identity, the relevance of Indigenous methodologies, and the complex and challenging power dynamics amongst researchers, and between researchers and Aboriginal communities. We will present on a participatory action-research project with graduate students which aims to stimulate individual and group reflection and discussion on these issues. This project is being jointly developed and executed by an Indigenous and a newcomer graduate researcher, and will be co-presented.

Native American pedagogy and health.
Brenda Seals, PhD, MPH (discussant)

Native Americans are challenging to reach with health education messages. Many elders and youth grow up with English as a second language. Few public health professionals understand either the diversity of the over 500 federally recognized tribes or the unique history and culture that are essential for effective messaging. Native Americans experience more poverty and substandard quality of life compared to other minority groups. Providing health care and outreach to Native Americans is also complicated by unique access to health care service issues and desires to blend traditional practices with Western Medicine. Despite these barriers, much can be done to improve messaging and education for Native Americans including: a) Building messages around family issues; b) Localizing messages focusing on community members’ experiences, art work and traditional stories; c) Providing story scenarios as the basis for health messaging; and d) Supporting community mobilization to help tribes and urban partners fully participate in and have ownership over health messaging.

Question & answer period

Tues, NOV 10, 8:30 am to 10:00 am:
Community perspectives on community-based progressive pedagogy (Session 4068.0, PCC 113A)

8:30 am
Suzanne Christopher, PhD and Lisa D. Moore, DrPH

8:35 am
“Will they really use our work?”: The importance of University/Community partnerships in creating relevant service learning assignments.
Jean M. Breny Bontempi and Chris Cole

Engaging public health students in learning the critical skills of conducting community-based participatory community assessments is made much more relevant when they are able to partner and collaborate with the community in a “real world” class exercise. This presentation will highlight an example of successful collaborative work with a community-based organization and a graduate community health education class to complete an agency-wide assessment for the agency’s strategic planning process. The project was designed and implemented entirely with equal partnership between course faculty and students and staff of AIDS Project New Haven (CT). Barriers to requiring service learning assignments, like this, from graduate students include their full-time work schedules, personal lives, and commuting distances resulting in a lack of time needed for students to work on-site at an agency. This experience showed that by taking on a participatory approach to conducting assessments and assigning students to working groups that met their own needs, the success of completing project was increased. The results for students, in working on a real project that will help an organization do its work better, was a motivating aspect of the process was the realization that their work would be used by the organization to improve services. By collaborating with community organizations, linking current public health issues at the local community level, and by researching organizations in the community, students realized that even the most diverse populations can be united by common goals. Making a “real difference” in the “real world” is at once inspiring and empowering.

9:00 am
Community based participatory research as a lens for reconceptualizing service learning: diverse urban students bridging campus and community.
Ester R. Shapiro, PhD, Michelle Rogers, BA, Asi Yahola Somburu, BA, Genita Johson, MD, MPH, Brian K. Gibbs, MPA, PhD, Naomi Bitow, MPH, Roland Smart, BA, and Felton Earls, MD

Service learning usually refers to residential college students assumed to be outsiders to the organizations they serve and focused on student learning and civic engagement rather than community benefit. Traditional service learning models exclude the majority of students enrolled in higher education, including ethnic minority and working-class students, who did not enroll in college full-time immediately after high-school, are commuter rather than residential students, work and care for families, and are already engaged in their communities. Community Based Participatory Research focused on health disparities offers a unique opportunity to inspire these students to undertake health professions and health research careers promoting health equity, through collaborative research addressing community problems in meaningful ways. CBPR research training supports diverse students, themselves carrying the consequences of health and educational disparities, in transforming academic and professional paths in ways that benefit their communities. While often regarded as deficits, first-hand experiences of health consequences of inequality, when combined with learning about the power of knowledge-based social action, inspire students to see participatory research as bridge and foundation for “making a living while making a difference”. This paper presents a collaboration between the University of Massachusetts at Boston, Harvard School of Public Health and Roxbury’s Cherishing Our Hearts and Soul Coalition in mentoring students who are members of communities affected by health disparities to gain research, community organizing, and policy/advocacy skills through CBPR. Presenters include faculty and community mentors and student researchers describing their experiences bridging professional development and community activism through participatory research.

9:25 am
Question & answer period

Tues, NOV 10, 12:30 pm to 1:30 pm:
Social Justice & Public Health: Student Posters (Session 4162.0, PCC Hall A/B)

This session highlights posters prepared by students of public health and health-related programs focused on intersections between social justice and public health from a historical, epidemiological, global, and/or methodological perspective.

Board #1: Evaluating the progress made towards Universal Health care for Philadelphians six years after a successful ballot referendum.
Jenny R. Pahys

Philadelphia is experiencing a health care crisis, specifically among poor and minority populations. After a successful grass-roots campaign, all wards in Philadelphia overwhelmingly approved a ballot referendum supporting universal health care for all Philadelphians in 2003. In response to this political mandate, the authorities instructed the Philadelphia Department of Public Health to act. The Department commissioned a report released in May 2005 titled Decent Health Care for All. Determining that an insurance strategy to provide health care for all Philadelphians was not feasible, this report called for the formation of an influential advisory board to best organize existing resources to efficiently deliver health services to underserved populations, produce strategies for better financing of care to vulnerable populations and to facilitate efforts to integrate ‘safety net’ programs for the uninsured. The mandate as such was thereby derailed.
This project assesses the progress made by the city towards acting on the primary suggestions outlined in Decent Health Care for All. This assessment discerns whether an effective advisory board and a health care agenda have been assembled and whether progress has been made towards the board’s primary objectives. Second, changes in health status of Philadelphians and available health care resources over the ensuing six year period are analyzed against the values underlying the original mandate. Finally, reflections on the progress to date are presented, including an analysis of the obstacles and enablers for change.

Board #2: Infrastructure, women’s time allocation, and economic development: a multidisciplinary theoretical model.
Pierre-Richard Agénor, PhD and Madina Agénor, MPH

Background: Research shows that infrastructure—namely access to safe water, sanitation, electricity, and transportation—may have a sizable impact on health outcomes in low-income countries. The detrimental effects of poor access to infrastructure on health disproportionately affect women—especially poor women in rural areas—who tend to allocate considerably more time to household production than men. No study has explicitly explored the role that women’s access to infrastructure plays in shaping the relationship between gender and economic development using a multidisciplinary theoretical model that draws on macroeconomics, gender studies, and public health. Methods: This paper uses a three-period, gender-based overlapping generations model to investigate how women’s access to infrastructure affects their time allocation and, in turn, economic development. Results: Greater access to infrastructure can increase the efficiency of women’s time allocated to home production and child rearing activities such that they can dedicate more time to market labor, education, and their own health care. These activities have a positive effect on economic development, as healthier and more educated women can make greater contributions to the economy. Discussion: This paper suggests that investing in women’s health is a productive activity, which could be best achieved by improving their access to infrastructure. While government expenditures on education and health contribute to economic development, public spending on infrastructure may have a greater impact on economic growth as a result of its effects not only on access to education and health services, but also on the efficiency of women’s time allocation.

Board #3: Public health and people with disabilities: where we are and where we need to go.
Dorothy E. Nary, MA and Chiaki Gonda, BGS

People with disabilities, one of the largest minority groups in the U.S., have made significant progress in the last 50 years to promote their civil rights. Passage of legislation such as Americans with Disabilities Act of 1990 has increased the participation of people with disabilities in the mainstream of society. Recent public health efforts, including the Surgeon General’s Call to Action to Improve the Health and Wellness of Persons with Disabilities and Healthy People 2010, have documented the health disparities experienced by this group and set objectives to address them. Additionally, the World Health Organization’s International Classification of Functioning, Disability, and Health [ICF] now recognizes disability as “a universal human experience” and takes in to account the social, and not just the medical, aspects of disability. All of these efforts have contributed to improved opportunity and quality of life for people living with a variety of disabilities. However, people with disabilities remain one of the most obese and sedentary populations in the U.S. and still experience significant barriers to accessing health care, health promotion and wellness services. This presentation will provide a demographic profile of people with disabilities in the U.S., explain the barriers to health and wellness experienced by this group, and describe emerging programs to promote their health.

Board #4: Issues in assessment of “race” among Latinos: implications for public health.
Vincent C. Allen, BA, Christina Lachance, MPH, Britt Rios-Ellis, PhD, MS, and Kimberly Kaphingst, ScD

Measurement of individuals’ race/ethnicity is an integral part of assessing and addressing disparities in health experienced by racial and ethnic minorities. However, the measurement of the social construct of race as it relates to Latinos has been the source of much debate. The unique historical and cultural experiences of Latinos related to race and racism has impacted individuals’ responses to measurement approaches. In particular, the selection of “some other race” in surveys (e.g., by 42% of Latinos in Census 2000) is a critical issue to consider. Meaningful characterization of this growing population is becoming increasingly important; however, data collection methodologies yielding ambiguous responses reveal little about the population. This issue has implications for how health data on Latinos is collected, reported, and interpreted, and to whom resources are allocated. The burden of disparities in health experienced by the Latino community makes the need for a more complete understanding of this population of particular importance. This paper examines Latinos’ selection of “some other race” when asked to classify their race, and how this relates to their historical experience and understanding of their racial identity. For example, research indicates that understandings of race among Latinos differ from the predominant U.S. conceptualizations of this construct, thereby affecting measurement. Data collection methodologies also impact reporting of race. We offer recommendations for measuring race and ethnicity in research and policy settings in ways that have the potential to yield more meaningful data that can be used to address the health needs of Latinos.

Board #5: Reducing disparities in emergency preparedness and response for people with disabilities.
Chiaki Gonda, BGS

Typically, people with disabilities are left out of the disaster preparedness and planning process (White, 2008). Recent research indicates that the majority of emergency managers are not trained in special needs populations, which includes people with disabilities (White, Fox, Rooney & Rowland, 2007). Recent major disaster incidents such as September 11 and Hurricane Katrina, Rita, and Ike have revealed disaster response shortcomings of the public health and emergency management systems to help get people with disabilities out of harm’s way during disaster conditions. This poster will describe key findings and recommendations from the research literature and identify resources and strategies to help reduce disparity for people with disabilities during disaster events or other emergencies.

Board #6: Formulating an evaluation and data collection plan for the Baltimore Cardiovascular Health Disparities Initiative.
Sushila Murthy, MPH, MD (C), Shannon Cosgrove, MHA, and Caroline Fichtenberg, PhD

The Baltimore City Health Department is proposing an Initiative to address cardiovascular disease. Cardiovascular disease is the city’s leading cause of death, the leading cause of a 6-year gap in life expectancy between the City and the state of Maryland, and the top reason for a 20-year range in life expectancy among neighborhoods within the city itself. The Initiative, to be launched July 2009, aims to bring successful community-based public health programs to scale citywide, translating research into practice and distributing resources to communities in need. The Cardiovascular Health Disparities Initiative includes five evidence-based components, each intended for populations that bear unequal burdens of cardiovascular disease: (1) health education through faith institutions – for women over 40, (2) disease management by community health workers – for underserved patients with known disease, (3) blood pressure screening and referral in barbershops – for at-risk men, particularly African American men, (4) Salt Task Force, (5) tobacco control. Each component requires careful data-collection and evaluation to assess overall program success and target improvement efforts. This paper will focus on evaluation of the first three components. Challenges include those of translating research into practice, namely having limited resources to increase the scale of interventions and subsequent data-collection. Additional considerations include choosing indicators to compare with State and national data and collaborating with community-based organizations to determine how evaluation tasks fall within their organizational capacity. This evaluation scheme seeks to make the Initiative sustainable and serve as an example for other large community-based programs aimed at reducing disparities.

Board #7: a new methodology to explore associations between neighborhood resources, race, and health.
Mark Brewster, David Hurtado, Sara Olson, and Jessica Yen

In recent years, interest in relationships between neighborhoods, the built environment and health has increased. One result of this has been the creation of This website allows users to enter an address and retrieve a ranking between 0 and 100, the Walkscore, by which users can then assess an address’s location-specific accessibility to neighborhood resources such as grocery stores, restaurants, bars, parks, libraries, and schools lying within the address’s one-mile radius. We investigated the association between Walkscore and health indicators for 15 Boston neighborhoods. Significant inverse correlations were found between Walkscore and neighborhood prevalence of overweight/obesity (r=-0.75, p=0.001), hypertension (r=-0.75, p=0.020), and lack of exercise (r=-0.60, p=0.018). Additionally, an inverse correlation was found between Walkscore and the percent of neighborhood population comprised by African-American residents (r=-0.61, p=0.001). No significant relationship was found between Walkscore and other race groups or with the percentage of neighborhood residents living below the federal poverty line. These findings suggest that Walkscore may be a promising tool for researchers and policy makers interested in exploring the relationships between neighborhoods and health. Furthermore, when linked with other tools, the relationship between Walkscore and the percent of neighborhood population comprised by African-American residents introduces new potential to ask and answer, through a historical and spatial lens, integrative questions relating health inequalities, racial segregation, and the built environment. We discuss interpretative considerations in using for health investigations, and suggest types of data still needed for further research.

Board #8: Individual and neighborhood level predictors of fear: an examination of the effects of violence and social capital at both the individual and neighborhood level.
Erin Richardson, MS

Background: Individual and area level factors are often both important in examining predictors of health. Neighborhood factors are especially important when examining residents’ perceptions of fear and safety. Fear and safety are inextricably linked and when residents are fearful in their neighborhoods, they are at risk for numerous negative health consequences in addition to the ones they are already concerned about with respect to safety. The purpose of this study is to examine the dual influences of experiencing both violence and social capital on both a personal level and a neighborhood level and assessing these influences (as well as other individual and neighborhood level factors) and their effects on residents’ perception of fear and safety in their neighborhoods. Methods: This is a retrospective, cross-sectional analysis using data from the 2003 and 2005 versions of the California Health Interview Survey (CHIS). Individual level factors that will be examined include four main domains with a multitude of factors within each domain. These individual level domains include demographics (e.g., race, ethnicity, sex, age), health services (e.g., health insurance status, unmet health care needs), risk/protective variables (e.g., social capital) and health (e.g., health status, prior victimization). Neighborhood level factors will also be examined and include two main domains. These two domains are physical environment (e.g., recreation facilities, public housing penetration, home ownership, crowding, incivilities) and social environment (e.g., crime, segregation, police presence, neighborhood social capital). These factors are being examined as two levels of influence on individual’s feelings of fear and safety.

Tues, NOV 10, 6:30 pm to 8:00 pm:
Spirit of 1848 Caucus Business Meeting (Session 441.0, PCC 105A)

Come to a working meeting of THE SPIRIT OF 1848 CAUCUS. Our committees focus on the politics of public health data, progressive public health curricula, social history of public health, and networking. Join us in planning future sessions & projects!

posted by Matt Anderson, MD

Disparity reduction, national budgets and human rights.

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The availability and allocation of budgetary resources says a lot about whether, how, and to what extent a government is committed and determined to implement its disparity reduction and thus its human rights-focused policies.
1. National budgets are a ‘black and white’ proof of whether governments are
putting-their-money-where-their-mouth-is. Through analyzing budgets, policies that promote equality between different income quintiles, between different ethnic groups, as well as between men and women can be identified. Therefore, for civil society to track the national budget is an essential tool in combating poverty, inequality and human rights (HR) violations.

2. There is a caveat though: Even if allocations are made in the national
budget, in many cases, allocated funds are not disbursed as planned for. Remember that national accounts are not audited immediately after the respective fiscal year ends. Therefore, ‘budget accountability’ has to be checked by HR activists throughout the year, because once accounts close the last day of each fiscal year nothing can be done anymore.

3. I am afraid effective disparity-reduction-policies –the way we want them to be singled-out and funded– are not and may-not-even-be reflected in budgets any time soon (and, by extension, governments are not likely to make much progress in reducing disparities…). That is a whole additional challenge: to exert the needed pressures for clearly singled-out poverty reduction measures to make it into the national budget to begin with.

4. That is why assuring a broad participation of the country’s representatives of the interests of people who happen to be poor and marginalized is so vital.

5. This marginalized group of society:

  • must be present in the diagnosis and analysis of the country’s poverty and ill-being situation,
  • must check whether assistance and services are delivered where most needed,
  • must annually participate in the national budget preparation process to check for any omissions or misallocations,
  • must, throughout the year, be vigilant of misappropriations or the blocking of financial resources (making sure funds do arrive at the places where they are supposed to be available for spending),
  • must participate in the monitoring of program outcomes as budgeted, and
  • must be vocal about all of the above and make ‘noise’ if they are of the opinion corrective actions are needed.

6. This Reader thus intends to, just briefly, remind you that national budgets (including foreign aid allocations that pass through the budget) are indeed a powerful, underutilized, instrument to keep authorities HR-accountable!


Claudio Schuftan, Ho Chi Minh City