Add a comment November 5th, 2009 by Matthew Anderson
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
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)
4:30
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.
4:35
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.
4:50
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.
5:05
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.
5:20
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.
5:35
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.
5:45
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
Introduction.
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: Walkscore.com: 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 Walkscore.com. 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 Walkscore.com 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
1 Comment March 30th, 2009 by Matthew Anderson
Tuesday, March 24, 2009 brought Dr. Martin Donohoe to Social Medicine Rounds at Montefiore. Dr. Donohoe, a Portland internist, is an Adjunct Associate Professor Department of Community Health, Portland State University. He is also a prolific writer and the editor of the Public Health & Justice Website (phsj.org). PHSJ contains a rich variety of materials on health topics such as Activism and Education, Women’s Health, Beauty, Body Modification, Cosmetic Surgery, & Obesity and Unnecessary Testing, Scams. A previous posting on the Social Medicine Portal discussed his critique of the diamond, gold, and flowers industry (See Alternative Valentine’s Day: No gold, No diamonds, No flowers?)
Tuesday’s talk examined “Corporate Control of Public Health: Case Studies and Call to Action.” Dr. Donohoe has made the slides available on PHSJ. In this posting we wanted to discuss one of his cases studies: Bringing Bad Things to Life: The Alliance between GE Medical Systems and New York Presbyterian Hospital. This case study is available as a slideshow on the PHSJ website or as an article published in the journal Synthesis/Regeneration. (A slightly longer version of the article is also posted on PHSJ.org)
The Agreement
On September 8 , 2003, General Electric and New York-Presbyterian Hospital announced “a historic multi-year, several hundred million dollar partnership” between GE Medical Systems and the hospital. As per the GE press release:
An integral aspect of the engagement will have NewYork-Presbyterian Hospital adopting GE’s acclaimed management development and performance improvement methods. This will help build upon NewYork-Presbyterian Hospital’s strong leadership team and employee base to deliver superior patient care well into the future. NewYork-Presbyterian Hospital will implement leading edge tools for improving management, service quality and operational effectiveness. Employees will be trained in GE’s quality and process improvement programs. This balanced approach is comprised of Six Sigma statistical methodologies, change-management strategies (Change Acceleration Process) and team-based problem solving techniques (Work-Out™).
The GE/NYP deal raised concerns about the corporatization of medicine that were voiced in 2004 in the New England Journal of Medicine by Dr. A. M. Garber (Business and Medicine: Corporate Treatment for the Ills of Academic Medicine). Garber noted the agreement – said to last ten years and involve $500 million dollars – offered a series of discounts and financing for GE products that would create an effective lock-in for GE medical equipment. While noting potentially positive aspects of this relationship, Gerber questioned the wisdom of such a lock-in. He also noted the potential conflicts of interest arising from GE’s dual role as management consultant and provider of equipment. Finally Dr. Garber raised concerns about the multiple ways in which corporate consultants might deal with economic pressures facing hospitals. He painted an elegant picture of the ways in which corporate thinking can undermine the social mission of the hospital:
But any consultant could also help a hospital’s financial performance by pursuing strategies that do not benefit the public. Many academic hospitals could improve their bottom lines by cutting the amount of uncompensated care they provide and eliminating unprofitable services. They might also promote excessive use of high-margin services. For example, to the extent that physicians induce demand, any hospital that owns a scanner — and any physician who earns fees by interpreting scans — can raise revenues by performing scans for less critical or even dubious indications. Similarly, well-reported phenomena such as “DRG creep,” “upcoding,” and “unbundling” can increase health care expenditures without benefiting patients. Such practices may seem innocuous from the individual patient’s point of view, if they merely raise health expenditures generally. But a physician or hospital that takes advantage of reimbursement anomalies can also jeopardize patients’ health. Physicians and hospitals can be reimbursed more if a candidate for the placement of multiple coronary stents has the procedure divided among two or more hospital admissions than if they are placed as part of a single complex procedure. Is it plausible that clinical needs alone explain why so many patients have stents placed as part of multiple admissions?
Concerns about the deal were also raised in an article in the New York Times entitled: The Conglomerate Will See You Now; Is What’s Good for G.E. Good for Health Care? which asked:
IMAGINE a small town where one person not only owns the hardware store, but is also the banker and the doctor’s most trusted adviser. In a sense, General Electric is trying to play such a role in the nation’s $2 trillion health care industry.
The New York Times article discussed the possibility that the agreement would foster the use of expensive technology, a major factor in rising health care costs. As noted by Gerber above, expensive diagnostic machines often generate their own demand.
New York Presyterian’s Dr. Herbert Pardes responded to the Garber article in a two paragraph Letter to the Editor (published in February 2005). Pardes stated: “Our collaboration with GE Medical Systems is based on having access to business skills and cutting-edge equipment that, in our judgment, will benefit our patients and increase our ability to provide cost-effective, high-quality care. We purchase from GE only technology that the hospital deems to be in the best interest of its patients. We will never delegate to a third party any decisions regarding our patients and the manner or method of our delivery of health care.”
Swimming with Sharks
Dr. Pardes’ reassurances ring far less convincing when we know a bit more about General Electric; this is the main topic of Dr. Donohoe’s article. General Electric is the world’s largest company by market share. In 2007 it had revenues of $168 billion and profits of $21 billion. For a bit of perspective GE’s revenues are larger than the GDP of over 2/3 of the UN member states. The corporation is built upon a diverse set of products and services including media (NBC, Universal Studios, Telemundo), consumer appliances, power, aircraft engines, insurance, transportation, business systems, and medical services/equipment (see the Columbia Journalism Review website). Through GE Power, the company is a major force in nuclear power.
General Electric does not have a stellar history as a corporate citizen. GE’s history of corporate malfesance is discussed Dr. Donohoe’s article and also in a 2001 article in The Multinational Monitor entitled “GE: Decades of Misdeeds and Wrongdoing.”
Rather than review this history in detail, we will focus on one of these misdeeds that is particularly close to our home: the pollution of the Hudson River with 1.3 million pounds of polychlorinated biphenyls (PCBs). These PCB’s were released between 1947 and 1977 from two of GE capacitor manufacturing plants and became a major focus of organizing along the river (discussed in a slideshow from Clearwater and a series of FAQ from Riverkeeper). Thanks to GE, two hundred miles of the Hudson River are now the EPA’ largest Superfund site (see http://www.epa.gov/hudson/). Of note this is just of of several GE superfund sites.
PCB’s are good neither for the environment, nor for health. The EPA states: “PCBs are considered probable human carcinogens and are linked to other adverse health effects such as low birth weight, thyroid disease, and learning, memory, and immune system disorders.“ General Electric has devoted tremendous resources into evading responsibility for the cleanup (see Richard Pollock’s Is GE Mightier Than the Hudson?) For GI’s side of this story, see their website.
Crade to Grave Care?
Dr. Donohoe closes his article on GE with the following reflection:
It is abhorrent to imagine GE profiting from New York-Presbyterian Hospital requiring that a patient’s developmental anomaly or environmentally-induced cancer (a result of exposure to GE toxins) be diagnosed by a GE scanner and treated with GE-manufactured therapeutic devices. This is a macabre twist on the concept of cradle-to-grave health care.
The question then is whether we should be looking to or partnering with corporations like GE for models on how to run health care.
Posted by Matt Anderson, MD
2 Comments February 25th, 2009 by Matthew Anderson
Tuesday February 24th’s Social Medicine Rounds brought Dr. Siobhan Dolan to the Residency Program. Dr. Dolan is double-boarded (Obstetrics and Gynecology, Clinical Genetics) as well as having an MPH. She currently works in the Montefiore/AECOM clinical genetics testing service.
Dr. Dolan began by discussing the difference between traditional clinical genetics and the current field of genomics. Genetics was originally concerned with single gene defects, usually associated with rare diseases. These mutations were usually of high penetrance (i.e. having the genetic mutation usually caused you to be sick) and caused conditions (like Down’s syndrome) in which environment played a relatively minor role. Genomics, on the other hand, typically involves multiple (often interacting) genetic variants that are associated with common conditions. These genetic variants often confer only a modestly increased risk of the disease. The diseases in question are ones (such as lung cancer) in which the environment plays a large role. (For more on this distinction, see the article by Alan E. Guttmacher, M.D., and Francis S. Collins, M.D., Ph.D. in the November 7, 2002 issue of the New England Journal of Medicine entitled: Genomic Medicine: A Primer).
Genomic medicine promised to make genetics relevant to everyone. In a 1994 article in the American Journal of Human Genetics, Dr. Eric Hoffman predicted “[t]he day of the personal DNA profile provided at birth, complete with calculated risks of various cancers, heart disease, and many other conditions could be actuality by the time that current first-year medical students begin to practice medicine.” While this prediction proved premature, a few years later genomics entered the mass market with internet-based direct-to-consumer advertising.
Dr. Dolan expressed considerable skepticism regarding the value of many genetic tests. In order to assess their clinical validity she recommended use of the ACCE criteria developed by the Foundation for Blood Research for the CDC. These criteria evaluate:
- Analytic validity: Does the test actually measure the genetic variation it is supposed to measure? (“ability to accurately and reliably measure the genotype of interest. “)
- Clinical validity: Is the genetic variation actually predictive to the disorder of interest? (“ability to detect or predict the associated disorder (phenotype)”)
- Clinical utility: What are the risks and benefits of introducing the test into clinical practice?
- Ethical, Legal and Social Consequences of the Test
The ACCE criteria suggest 44 specific questions that should be answered in considering a given genetic test.
Several genetic tests have not lived up to their initial promise. For example, Roche’s AmpliChip CYP450 test was touted as a breakthrough that would allow individualized dosing, particularly of psychiatric medications. But the clinical utility of the test has been questioned (The Medical Letter, 47(1215/1216), August 15/29, 2005). In 2007 the Evaluation of Genomic Applications in Practice and Prevention (EGAPP) Working Group writing in Genetics in Medicine concluded that: No evidence was available showing that the results of CYP450 testing influenced SSRI choice or dose and improved patient outcomes, or was useful in medical, personal, or public health decision-making.” [SSRI's are a common class of anti-depressant drugs].
Similar concerns have been raised about pharmacogenetic testing for warfarin. Reviewing commercial tests for CYP450 polymorphisms associated with differences in warfarin metabolism, The Medical Letter concluded in May of 2008 that: “Currently available data are probably insufficient to recommend pharmacogenetic testing just yet for all patients taking warfarin, but these tests may be helpful, especially in selecting an initial dose and in some patients with unexpected therapeutic responses to the drug. Whether they improve clinical outcomes remains to be established.” (The Medical Letter, 50(1286), May 19, 2008)
Regardless of these cautions genomics has now entered the world of direct to consumer advertising and Dr. Dolan reviewed the major categories of this fascinating “brave new world”. [Please note, we are not endorsing the use of any of these websites.]
1. Determining Paternity. DNA Lab Centers features a smiling baby on the home page with the caption: “Does he really have your eyes?” Results can be used to “provide Maternity, Paternity, Immigration, Grandparent and Sibling Testing/Verification.” The use of DNA for immigration cases is, apparently, a growing field.
2. Sites like Ancestry.com offer genetic testing which purport to allow one to investigate ancestry.
3. Dating and Social Networking: Sites like Gene Partner and Scientific Match claim to match people based on genetics. Gene Partner bases its system on HLA matching and the site provides references to 11 scientific publications. Four of these were non-human studies and three of the studies are listed twice (ouch!). Of the remaining four studies three relate to female preferences for different male odors and only one associates HLA types with romantic involvement, a study involving 48 couples. Not a particularly strong evidence base. Scientific Match seems also to use the HLA types, but the site is less explicit.
4. Sites looking for specific medical disorders: Sites like DNA Direct and 23 and me provide comprehensive genetic testing services include whole genome tests. Again, the clinical utility of most of these tests has yet to be demonstrated.
It is a shame that the development of genomics in the United States is being left to the marketplace. The British are rightly proud of their National Institute for Health and Clinical Excellence (NICE) which evaluates new drugs and devices prior to their adoption by the National Health Service. NICE’s decisions has been controversial at times, but this is to be expected given the nature of the decisions it makes. The new Federal stimulus bill sets aside $ 1.1 billion dollars for effectiveness research. This is a welcome move and long overdue.
Concluding thoughts:
Maybe major histocompatibility genes truly explain romance. But in the market, let the buyer beware.
I prefer poetry and will close with the thoughts of Edmund Spenser:
Amoretti XXX: My Love is like to ice, and I to fire
My Love is like to ice, and I to fire:
How comes it then that this her cold so great
Is not dissolved through my so hot desire,
But harder grows the more I her entreat?
Or how comes it that my exceeding heat
Is not allayed by her heart-frozen cold,
But that I burn much more in boiling sweat,
And feel my flames augmented manifold?
What more miraculous thing may be told,
That fire, which all things melts, should harden ice,
And ice, which is congeal’d with senseless cold,
Should kindle fire by wonderful device?
Such is the power of love in gentle mind,
That it can alter all the course of kind.
Posted by: Matt Anderson, MD
January 6th, 2010 will mark the beginning of the Albert Einstein College of Medicine student-run Social Medicine Course. This course is a unique opportunity for the Einstein students to cover “essentials of medical practice not taught in medical school.” This year’s list of speakers amply illustrates the connections between clinical practice and social activism.
The work of Dr. Martin Donohue is no stranger to the portal. (See our previous postings on 
In August of 2009, the WHO’s Commission on the Social Determinants of Health issued a bold call to eliminate health disparities within a generation. Three articles in this issue look at what has – and has not – happened in the intervening year. Our second editorial examines the international response to the Commission’s call. José Carlos Escudero explores the meaning of the report for the WHO and underscores the report’s limitations. A detailed critique of the report, along with an alternative approach to addressing health inequities, is offered by Dr. Anne-Emanuelle Birn. Dr. Birn’s critique is especially important for offering important historical background by exploring how Europeans in the 19th century – notably Louis-René Villermé, Edwin Chadwick, and Friedrich Engels – each approached the social disparities that arose during the Industrial Revolution.
We are also very pleased to publish three classic texts describing the Peckham Experiment, an innovative community center built in England during the Depression. The 
