The Social Medicine Portal

2010 AECOM Student-Run Social Medicine Course

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 opening speaker will be Dr. Joia Mukerjee of Partners in Health who will discuss “Social  Forces in Medicine.”  This event will take place at 5:30 PM at the Riklis Auditorium and will be followed by a reception. Subsequent sessions will take place each Wednesday (with one exception) at the 5th floor Forchheimer Auditorium at 5;30PM. Dinner is provided.  All events in this series will be listed at the top of our blog roll.

At last year’s course several local readers of the Social Medicine Portal dropped by.  Please feel free to come, but write to Ms. Karp (see below) so that we can inform security.

The list of speakers and topics is as follows:
Jan 13 ∙ History of Social Medicine ∙ Matt Anderson, MD, MS.
Jan 20 ∙ LGBT Health and Community Organizing ∙ John-Paul Sanchez, MD, MPH
Jan 27 ∙ Race and Health in the Bronx ∙ Robert Fullilove, EdD
Feb 3 ∙ Harm Reduction in the Bronx: Dealing with the Hepatitis Epidemic among IV Drug Users ∙ Donald Davis
Feb 10 ∙ Motivational Interviewing and Nutrition in the Bronx ∙Yasmin Mossavar-Rahmani, PhD, RD, CDN
Feb 17 ∙ The Impact of Hep B on Pregnancy in the Asian American Community∙Tomoaki Kato, MD; Maya Gambarin-Gelwin, MD
Feb 24 ∙ Abortion Care in NYC∙Marji Gold, MD
Mar 3 ∙ Native American Health ∙ Donna Perry, MD *Price Center Auditorium
Mar 10 ∙ Separate and Unequal: Medical Apartheid ∙ Neil Calman, MD and Nisha Agarwal, JD
Mar 16* ∙ Liberation Medicine ∙Lanny Smith, MD, MPH, DTM&H  *Tuesday at 7:15pm*
Mar 17 ∙ Reentry: Old Fears, New Hopes ∙Meekaelle Joseph
Mar 24 ∙ Street Medicine ∙ Jim Withers, MD
Apr 7 ∙ The History and Practice of Community Psychiatry ∙Thomas Betzler, MD
Apr 14 ∙ Nyaya Health: A Case Study in Developing a Healthcare NGO∙ Ryan Schwarz and Bijay Acharya, MD
Apr 21 ∙ Refugee and Asylee care: Human Rights for Torture Survivors ∙ Nicole Sirotin, MD
Apr 28 ∙ Ayurvedic Medicine ∙Bhaswati Bhattacharya, MD, PhD
May 5 ∙ The War on Women: Criminalization of Reproduction in the United States ∙Robert Roose, MD

For any questions or kosher meal requests, please contact Jessica Karp at jkarp@einstein.yu.edu.

Posted by Matt Anderson, MD

2009 Spirit of 1848 sessions at APHA

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

Public Health & Social Justice Website

The work of Dr. Martin Donohue is no stranger to the portal.  (See our previous postings on GE, NY-Presbyterian Hospital & the Hudson River Clean-up and Alternative Valentine’s Day: No gold, No diamonds, No flowers?)  He wrote to us recently that he has updated most of the presentations on his website Public Health & Social Justice.  He noted that: “as always, the powerpoints are open-access, and I am always looking for submissions from health professionals at all stages.”

Here are some of our favorite selections from the dozens of slideshows, articles, and syllabi available on the site:

• The syllabus from Dr. Donohue’s  Public Health and Social Justice Course. How can one fail to be intrigued by a public health course that starts with a reading of Michael Parenti’s How Wealth Creates Poverty in the World?  A listing of slideshows and papers from this course can be found at this link.
• A slideshow on the the links between Luxury Care & Academic Medicine.  This includes a discussion of strategies adopted by cash-strapped academic medical centers such as paying to provide care to sport teams in return for publicity, recruiting high-income foreign clients, and creating boutique clinics (such as travel clinics for travel to exotic locations).
• An article, by contrast, from the Journal of Health Care for the Poor and Underserved on the health problems of migrant and seasonal work.
• A slideshow on Scans and Scams discussing “direct-to-consumer marketing of unnecessary (and potentially harmful) screening tests; also covers CT scan controversies and health care fraud.”
• An entire page of articles devoted to the “adverse health, environmental, and human rights consequences of flowers, gold, and diamonds.”  It is important to note that Dr. Donohue offers alternative ways of offering tokens of love.
• An article on The history of hysteria from which we learn: “Egyptian papyri from 1900 B.C. (the Kahun Papyrus) recount curious behavioral disturbances in women (chronic fatigue, difficulty seeing, diffuse myalgias) thought to be caused by a wandering uterus. Symptoms were thought to result from the crowding of other organs when the uterus ascended into the abdomen. The belief that the uterus behaved as an autonomous, maverick organism within a woman led to treatments based upon that, such as fumigating the vulva with precious and sweet-smelling substances to entice the uterus back into the pelvis, while repelling it from the upper abdomen by ingesting foul-tasting foods or inhaling putrid smelling substances.“

posted by Matt Anderson, MD

New issue of Social Medicine (V4N3) Just Published

Social Medicine, our open-access, online academic journal has just published its latest issue. Here is a brief summary of the articles all of which are available for free at www.socialmedicine.info and www.medicinasocial.info (in Spanish).

Children in post-Civil War Nepal singing revoutionary songs

Special Theme: Social Medicine & War

For this special theme issue on Social Medicine & War, Dr. Vic Sidel served as guest editor. His lead editorial (co-authored with Dr. Barry Levy) examines the diversion of resources to war and the preparation for war.

Quoting from their introduction to the three original research articles about war, Drs. Sidel and Levy write:  ”Dr. Andrea Angulo Menasse, a researcher from Mexico City’s Autonomous University, documents the very personal story of how the violence of the Spanish Civil War affected one family. In her case study the trauma suffered by Spanish Republicans is traced through three generations and crosses the Atlantic Ocean as the family moves is exiled in Mexico. Dr. Sachin Ghimire from the Centre of Social Medicine and Community Health of the Jawaharlal Nehru University reports on his fieldwork in Rolpa, Nepal, the district from which the Nepal Civil War (also called the People’s War) originated in 1996. Based on 80 interviews, he documents the difficulties faced by health care workers as they negotiated the sometimes deadly task of remaining in communities where control alternated between Nepalese Special Forces and the Maoist rebels. Finally, Colombian researcher, Carlos Iván Pacheco Sánchez, from the University of Rosario in Bogota, brings an epidemiologist’s tools to examine the impact of the ongoing armed conflict in the border Department of Nariño. His discussion is informed by the current debate over health care in Colombia where a recent Constitutional Court decision has found that the current health care system violates the right to health.”

Closing the Gap: Where are we one year later

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.

The Peckham Experiment

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 Pioneer Health Center was designed around the idea of studying (and fostering) what makes people healthy, rather than what makes them sick. Imagine that!

Please visit the journal and explore the breadth, depth and scope of social medicine past and present. Along with some suggestions for the future.

posted by Matt Anderson, MD

Dr. Martin Donohoe: GE, NY-Presbyterian Hospital & the Hudson River Clean-up

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

Social Medicine V4N1: Health Activism from Philadelphia to India

We have just published the 12^th edition of Social Medicine/Medicina Social, our bilingual, online journal.  It is available in both English and Spanish.  Our 12th issue captures the stories and struggles of diverse health activists, among them Dr. Walter Lear (shown below):

US Health Activism Collection

Last summer we had an opportunity to interview Dr. Lear (now 85 years old), founder of the US Health Activism Collection.   In a wide-ranging interview in his home Dr. Lear discussed his personal background, the origins and purpose of the collection, the impact of the McCarthy period on the US health left, as well as his vision for the future (available at this link).  Dr. Lear later added copious footnotes to his interview creating a virtual “Who’s Who” of the mid-20th century US health left.

Dr. Lear also allowed us to make PDF copies of two of the pamphlets in his collection. These are Autopsy on the AMA: An Analysis of Healthcare Delivery Systems in America [1970] published by the Student Research Facility and Your Health Care in Crisis: A HEALTH/PAC Special Report [1972] [Both documents are a bit long and may take some time to download.]  Although HEALTH/PAC no longer exists as an organization, there is a HEALTH/PAC website.

Seize the Hospital to Serve the People

We are also publishing a video of Cleo Silvers, a remarkable Bronx health activist who was involved in the takeover of Lincoln Hospital.  (For more on this take over see our spring 2007 journal)  The video of Ms. Silvers can be seen at our Audio/Visual tab.

Should India Use Commercial Ready To Use Therapeutic Foods (RUTF) For Severe Acute Malnutrition (SAM) ?

Indian Activists associated with Jan Swasthya Abhiyan (People’s Health Movement – India) and the Right to Food Campaign question the value of Plumpy Nut, an Ready to Use Therapeutic Food (RUTF).  They argue that locally produced alternatives are cheaper, more acceptable, and serve to strengthen communities.  At the very least Plumpy Nut should have been compared to local supplements before being adopted by the government.  Available at this link.

Combatting Organ Tafficking

Activists Debra A. Budiani and Kabir Karim of the  Coalition for Organ-Failure Solutions discuss the social roots of organ trafficking and consider the implications of  a 2008 WHO resolution and the Istanbul Declaration.  Available at this link.

posted by Matt Anderson, MD

Dr. Siobhan M. Dolan:“Direct to Consumer Genetic Testing: Are We Ready?”

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

A Peer Review of “Good to Great” by Jim Collins

One of the solutions offered to the chronic crisis in US health care is to introduce the “rationality of the market.”  Overseas this has meant the introduction of US-style HMO’s and the privatization of national health care systems.  In the US, hospitals – even not-for-profits – are forced to adopt the methods and vocabulary of business.  Patients become customers, clinical care becomes one more product line.

Symptomatic of this trend is the proliferation in health care settings of business oriented books on management.  Some, such as Stephen C. Beeson’s Practicing Excellence: A Physician’s Manual to Exceptional Health Care and Fred Lee’s If Disney Ran Your Hospital: 9 1/2 Things You Would Do Differently are specifically written for the health market. Others are generic management books such as Peters and Waterman’s In Search of Excellence: Lessons from Americas Best Run Companies or Jim Collin’s Good to Great: Why Some Companies Make the Leap… and Others Don’t.

In clinical practice we strive (often not all that successfully) to base our actions on the best available evidence.  This is the general idea behind what is called evidence-based medicine (EBM).  It is striking, then, that the advice presented in these business books often seems to lack any supporting evidence other than a series of colorful anecdotes mixed with the equally colorful opinions of the author.  This is what we in medicine have come to call “expert advice” and it is considered the lowest form of evidence for adopting a particular therapy.  Expert opinion is not valueless, but there are better ways of getting at the truth.

The question occurred to me: What would happen if EBM standards were applied to the management books coming to medicine from the business community?

To answer this question I decided to write a peer review of Collin’s book From Good to Great. I write peer reviews for medical journals on a fairly regular basis and have some advanced (Master’s level) training in clinical research methods.  Of course, I do not have content expertise (i.e. specific knowledge) in the business world.  In addition, unlike most peer reviews, I know who is the author and also know a bit about the reaction to this books.  So my review is not blinded.  But with those caveats in mind, here is a peer review of Jim Collin’s Good to Great:

* * * *

Thank you for the opportunity to review this book.

Summary:

Jim Collin’s book,Good to Great: Why Some Companies Make the Leap… And Others Don’t sets as its project to understand what makes companies great. The book is about the question “Can a good company become a great company and, if so, how? – and our search for timeless, universal answers that can be applied by any organization. (pg 5). [Although the research was conducted by a team I will refer to "the" author in this review.]

The author tries to answer this question using a case-control methodology.  The author examined the universe of Fortune 500 corporations between the years 1965 to 1995.  From this group of over 1400 companies, he selected those that had made a transition from being good companies to being great companies.  This was done by finding corporations that had a 15 year period of average or below average stock returns (the “good” period)  followed by an 15 year period during which stock returns were three times average stock market returns (the “great” period).  Only 11 companies (00.77%) out of a universe of 1,435 met these strict criteria. They were then paired with control companies within their own industries whose stock returns were average during the same 30 year period.

To assess what factors might explain the success of the control companies the author then examined available public records about these 11 pairs (22 corporations) including financial records and published reports.  The author also conducted 84 interview with the senior management and board members of the 11 case companies; no interviews were conducted with the control company management or board members.

Based on analyses the author and his team reached a series of conclusions which they report as being “empirical deductions directly from the data.“  In the space of this brief review I will not comment on all of their findings since I will focus my review on the methodology.  Let me just briefly touch on several findings which characterize the flavor of the book:

1. Leadership is key in the transition from good to great, particularly what the authors call “Level 5″ leaders. Level 5 leaders are characterized by being modest (i.e. not self promoting), but intensely devoted to the mission of the company.

1. “Good to great companys are more like hedgehogs – simple, dowdy creatures that know “one big thing” and stick to it.  The comparison companies are more like foxes – crafty, cunning creatures that know many things yet lack consistency.”

1. The Flywheel concept: Good to great transformations “never happened in one fell swoop.  There was no single defining action, no grand program, no one killer innovation…” Rather there was “persistent pushing in a consistent direction over a long period of time…”

The various “good to great” principles are considered generalizable so that “almost any organization can substantially improve its stature and performance, perhaps even become great, if it conscientiously applies the framework of ideas we’ve uncovered.” (page 5)

The author has also published a Good to Great for the Social Sector which applies the principles of the book to the “social sector.”  This does not appear to be based on any independent analysis of data but rather on how the author sees his principles enacted in the social sector.  I will not discuss this since it is, in a sense, a series of case histories.

General Comments:

The author’s general project of distinguishing “good” companies from “great” companies needs better justification.  Bad, good, and great companies (in terms of stock returns, the author’s metric) may fall upon a continuum without clear dividing lines.  This can be illustrated with a simple, perhaps extreme, example.  If one evening we were to follow a random group of 1435 gamblers playing slot machines at a casino in Atlantic City we would find a wide variety of outcomes from those who lost money, to those who broke even and those who won large amounts of money.  We could pair the high winners (the top 11 gamblers) with the average winners and try to understand the differences between the “good” gamblers and the “great” gamblers.  Given the human propensity to find reasons for anything, we might develop a theory of how great gamblers are different from good gamblers. But this would be nonsense.  [This problem is similar to the  "Texas Sharpshooter Fallacy"]

The author states the leaders of “great” companies “attribute much of their success to good luck, rather than personal greatness.” (p. 40). He states that this emphasis on good luck was puzzling.  “After all, we found no evidence that the good-to-great companies were blessed with more good luck… than the comparison companies.”  [This evidence and methodology for this statement is not presented] The author concludes that his interviewees are simply displaying modesty, a trait of great executives.  But is the author perhaps not imposing his interpretation over that given by the interviewees?

A second important comment is that stock returns were the sole criteria for excellence.  Thus Philip Morris, a tobacco company, is one of the 11 great companies. Cigarette smoking is the number one preventable cause of death in the US.  Thus the inclusion of Philip Morris as a great company highlights the  highly limited and certainly controversial definition of greatness.  The author states that other criteria for excellence such as societal impact or employee welfare were not considered because  “we could not conceive of any legitimate and consistent method for selecting on these other variables without introducing our own biases.” [pg 6]

This statement strikes this reviewer as odd.  Is the sole criteria of profit really unbiased and value-free?  Is it neutral to accept that as long as you make a profit, it’s ok to sell a product that kills people?  In the author’s attempt to avoid bias, he merely reveals his lack of awareness of his own fundamental biases. This lack of self consciousness is of concern in an investigator.

It is also of particular concern to this reviewer that the author strives to find “timeless, universal answers.”  To quote Stephen Penn’s Dicing with Death: Chance, Risk and Health “…the defining characteristic of science is not its infallibility but rather its self-correcting ability.” [p. xi].  This is especially true of case-control studies which are subject to multiple biases and whose results should always be confirmed by other stronger methodologies.

Methods:

Variance from accepted research practice

The purpose of a case control study is to compare cases and controls.  It is unclear why management in the control companies was not interviewed.  I would argue that absent such control interviews, information obtained from case interviews should not be included in this study.

Limitations of the case control methodology

Even accepting the interview data, this data is subject to important biases:

• Given the 15 year period of good returns necessary to become a case, any information obtained by the authors regarding the “transition from good to great” will refer to a time period at least 15 years prior to the study. In other words, a “great company” in 2000 would have made the “transition” in 1985.  Other transitions might have occurred far earlier. This long delay limits the value of any interview data. People are being asked to provide detailed answers about events that occurred at least a decade and a half before the interviews. Many of the important people at the time of the transition may be dead or unavailable.  This may introduce biases which the author does not address.
• Case control studies are bedeviled by the problem of recall bias.  For example, women who give birth to children with birth defects are likely to remember more about the drugs they took before and during pregnancy than mothers whose children were normal.  One anticipates this as a major problem when executive are asked to explain “the transition” (this was the wording of the question posed to them, p. 239).
• It seems plausible that interviewees would be very unlikely to offer socially unacceptable answers. For example, executives who engaged in illegal, immoral or grey activities (such as aggressive political lobbying) are unlikely to reveal these during interviews regarding their success. These are also precisely the types of data that are unlikely to be found in the public record.
• I am struck by the fact that the authors interviewed senior management and members of the board. Surely there are more people in a corporation than those at the top. This is an important bias which I think weakens the evidence base for the author’s conclusions on the centrality of management.

Case control studies cannot control for confounding.  In other words it may be that some factor X accounted for both Level 5 management and corporate success.  In addition, even assuming that the associations found by the authors are valid it does not necessarily follow that level 5 management “caused” the success.  It may be that the success “caused” the Level 5 management, a point I will return to.

Case control studies may provide interesting hypotheses but they should not be considered as proven without other lines of evidence.

Questions concerning theoretical models

The author uses the “hedgehog and fox” explanatory model derived from an essay about intellectuals by Isaiah Berlin.  It may be that this concept can be easily extrapolated from intellectual life into the business world, but the author offers no proof that in fact this is a good model to understand business behavior.  One would have preferred that he demonstrated that independent raters would have reached similar conclusions about the fox-iness and hedgehog-iness of companies before accepting this schema.

Similarly, I believe that the topology of management types requires some justification.

Statistical Analysis

No formal statistical analysis is presented although formal statistical input was sought (see pages 211-212).  One mathematician pointed out that the sample was non-random and that therefore differences between the samples would be non-random. And a second statistician made a calculation about how non-random.  Again this simply reflects the purposeful sampling technique.

Results

General Schema

One of the most dramatic images of Good for Great is the flywheel, shown here.  What is interesting is that the central image of the flywheel, the two companies diverging at the center-  one to goodness, the other to greatness – is a not finding of the study. It is a result of the way the study was structured. The author has simply put his explanatory model on a highly unusual pairing.

Level Five Leadership:

The author makes a great point of emphasizing that he initially decided to “downplay the role of top executives so that we could avoid the simplistic ‘credit the leader’ or ‘blame the leader’ thinking common today.” [p. 21]  But the author argues that “the data won” and the centrality of leadership was one of his findings.

But is such a finding not inevitable given the author’s methodology?  One might logically begin with the idea that what makes a “great” retailer is different from what makes a “great” drug company.  But the author assumes that “greatness” characteristics are  independent of industry. This is an assumption that is neither discussed nor justified.  It may however derive from his central bias that the goal is of the corporation is to make money regardless of the social consequences.  However, having made greatness independent of industry, we are left only with greatness explanations involving something intrinsic to the corporate structure per se.  It is hard to see how such a project – fed by press reports and management interviews – cannot but conclude that what distinguishes great corporations are the policies of their leaders.  The author himself also may have a bias towards looking for management-centric answers.  He wants to find the way to make a good corporation great and any principles will have to be implemented by management.

Generalizability: On page 5 the authors state that as a result of their research: “… one giant conclusion stands above the others: We believe that almost any organization can substantially improve its stature and performance, perhaps even become great, if it conscientiously applies the framework of ideas we’ve uncovered.”  There is no empiric evidence supporting this statement since – at the time of publication – no organization had attempted to create change by applying the ideas outlined in the book.  In other words, while it may be true that people who drink alcohol have less heart disease, this does not mean that if I start drinking alcohol I will reduce my risk of cardiac disease.

I think this conclusion illustrates the author’s incautious approach to his data and calls into question the validity of his findings.

Causality

The author claims the good-to-great principles caused the transformation of the companies.  But it is also possible that the chain of causality worked the other way.  Let us consider the hedgehog principle.  It is possible that success causes companies to focus on what they are doing well rather than visa versa.  Or that companies function as flywheels because they are making profits.  Not visa versa.

Advice to the author

As noted above case control studies are useful for generating hypotheses.  If the author believes his hypotheses are correct there are several ways in which they could be tested empirically.  One simple way would be to present his data in a blinded fashion to independent researchers and see if similar conclusions would be drawn. Another way would be for the author to make predictions based on his schema and see how accurate such predictions would be and/or to see if independent observers using his framework would make the same predictions.

Conclusions:

I would not publish this book in its present form. I think the author should present his conclusions as hypotheses and discuss ways in which they might be empirically validated.  There should be a formal statistical analysis.

* * * * * * * *

This is my peer review of Good to Great.

Given the methodological weaknesses of this book it is intriguing to ask why it is so successful.  What is it about the “good to great” story that makes it so attractive?  Why do people in health care – who really should know better – accept this poor quality research?

The book’s veneer of scientific rigor is clearly important in establishing the authority of its conclusions.  Yet it seems to me that the central attraction of this book lies in its endorsement of the essential morality of the capitalist market.  People who are modest, dedicated, hardworking, and determined can achieve greatness, i.e. make lots of money.  Virtue is rewarded even in a tobacco company. This is a satisfying morality tale which seems to be validated by science.  This seems to be the key to the book’s commercial success.

Health care personnel venturing out into the world of business books should, however, remember that the market is not characterized by morality and rationality.  Remember the Roman adage: Caveat emptor.  Let the buyer beware.

Whenever I write a review, I always request feedback from the editor.  Let me know what you think.

Posted by Matt Anderson,MD

Dollars & Sense and Dr. Ichiro Kawachi on Inequalities of Health & Wealth

Dollars & Sense is a bimonthly magazine “of economic justice” produced by the Economics Affairs Bureau, Inc, a not-for-profit publisher in Boston.  EAI also publishes a series of “Real World” books which cover a variety of topics such as macroeconmics and political economy.  All the issues of Dollars & Sense are available on the web and – together with their blog – provide some welcome critical orientation on the current economic crisis.  Interested readers may want to look at Larry Peterson’s series: The Subprime/Securitization Market Panic: A Guide for the Perplexed.

Earlier this year D&S interviewed Ichiro Kawachi, of Harvard’s School of Public Health reagarding the effects of income inequality on health.  In this interview Dr. Kawachi discusses his views on how both absolute income levels and relative inequality affect health:

“Most obviously, income enables people to purchase the goods and services that promote health: purchasing good, healthy food, being able to use the income to live in a safe and healthy neighborhood, being able to purchase sports equipment. Income enables people to carry out the advice of public health experts about how to behave in ways that promote longevity.

But in addition to that, having a secure income has an important psychosocial effect. It provides people with a sense of control and mastery over their lives. And lots of psychologists now say that sense of control, along with the ability to plan for the future, is in itself a very important source of psychological health. Knowing that your future is secure, that you’re not going to be too financially stressed, also provides incentives for people to invest in their health Put another way, if my mind is taken up with having to try to make ends meet, I don’t have sufficient time to listen to my doctor’s advice and invest in my health in various ways.

So there are some obvious ways in which having adequate income is important for health. This is what we call the absolute income effect—that is, the effect of your own income on your own health. If only absolute income matters, then your health is determined by your income alone, and it doesn’t matter what anybody else makes. But our hypothesis has been that relative income might also matter: namely, where your income stands in relation to others’. That’s where the distribution of income comes in. We have looked at the idea that when the distance between your income and the incomes of the rest of society grows very large, this may pose an additional health hazard.”

Dr. Kawachi’s interview updates the concept that relative income inequality, in addition to absolute levels of wealth, is an important determinant of health. This idea has been debated for several decades in Britain. It had been hoped that the introduction of the National Health Service would eliminate health disparities by providing universal and equal access to care.  However the publication of the Black Report in 1980 revealed that health inequalities persisted in the “socialist” NHS.  In response Ruskin College Oxford and the Socialist Health Association prepared a series of reports.  The fourth, Income and Health,  was published in 1991. It was written by Allison Quick and Richard Wilkinson and began:

“The key argument of this report can be stated in three sentences.  Overall health standards in developed countries are highly dependent on how equal or unequal people’s incomes are.  The most effective way of improving health is to make incomes more equal.  This is more important than providing better public services or making everyone better off while ignoring the inequalities between them.’

From this argument derives a socialist commitment to income equality.  Interested readers may want to look at the Socialist Health Association’s Health Inequalities Policy Statement for the practical implications of this viewpoint. Of course, “socialism” was recently used during the US Presidential campaign in an attempt to “smear” President-Elect Obama.  So the concept of increasing income equality is, frankly, off the table.  And one does not think to ask if income and social inequality are both not intrinsic and necessary in a capitalist economy.

Dr. Kawachi’s interview updates the thesis of Quick and Wilkinson with modern evidence.  He cites the 2006 JAMA study showing that Americans – with higher levels of income – are less healthy than our British counterparts and he suggests some more technical solutions designed to bring economics to the service of health, such as Health Impact Assessments (HAI).

I have been disturbed by the emphasis on the psychological impact of health inequality. This was a prominent part of the recent PBS series Unnatural Causes.  One cannot help escape the feeling that the practical implications of this theory are not the promotion of income equality, but rather the teaching of the exploited to relax and accept their fate.

posted by Matt Anderson

Spirit of 1848 Presentations at the American Public Health Association 2008

Berlin Revolution, March 1848

The Spirit of 1848 (www.Spiritof1848.org) is a network of progressives dedicated to “politics, passion and public health.” They are perhaps best known for their very active listserve and their well-attended sessions at the American Public Health Association.  They recently circulated a report about the Spirit of 1848 sessions at the October 2008  APHA conference in San Diego.  The report offers an exciting picture of critical and activist scholarship in public health.

If you are curious where the name “Spirit of 1848″ comes from, see the explanation on their website.  It’s probably worth noting that the term “social medicine” was coined in the year 1848 independently by Rudolf Virchow in Berlin and Jules Guerin in Paris.

What follows is taken from their report.  It will shortly be available on their website.

The Spirit of 1848 at APHA 2008

In brief, we grew out of the work in the late 1980s of the National Health Commission of the National Rainbow Coalition, we cohered as the Spirit of 1848 network in 1994 and began organizing APHA sessions as an affiliate group to APHA that year. In 1997 we were approved as an official Caucus of APHA, enabling us to sponsor our own sessions during the annual APHA meetings.

• We have 4 sub-committees:
  • politics of public health data,
  • progressive pedagogy & curricula,
  • history (with the sub-committee serving as liaison to the Sigerist Circle, an organization of progressive historians of public health & medicine), and
  • e-networking, which handles our listserve and website.
• To ensure accountability, all projects carried out in the name of the Spirit of 1848 are approved by the Spirit of 1848 Coordinating Committee. The Coordinating Committee communicates regularly (by email) and its chair (and other members, as necessary) deals with all paperwork related to organizing & sponsoring sessions at APHA and maintaining our Caucus status. The subcommittees also communicate regularly by email in relation to their specific projects (e.g., organizing APHA sessions).

Below is a brief summary of the highlights of each session, in chronological order.

1) SOCIAL HISTORY OF PUBLIC HEALTH
Our provocative session was attended by ≈ 100 people (about the same as the ≈ 120 in both 2006 and 2005 and more than ≈ 70 in 2007 and ≈ 45 in 2004).

HISTORY, BORDERS, IMMIGRATION, AND PUBLIC HEALTH: FROM 1848 TO 2008 – 160 YEARS OF DEBATE
MON, OCT 27 ***10:30 AM-12 NOON (SESSION 3159.0) *** SD CONV. CENTER (SDDC) RM 7A
10:30 AM — Introduction: Border conflicts and negotiations: a hidden history of public health. Luis Alberto Avilés, PhD & Kirby Randolph, PhD, but presented by Anne-Emanuelle Birn, MA, ScD
10:35 AM — Commercial and social disturbance and restrictions at the U.S.-Mexico border (1819-1924): an improvement to the public’s health? Ana Maria Carrillo, PhD
11:00 AM — Medicalizing borders and immigrant bodies: immigration & public health policy in the 20th century. Natalia Molina, PhD
11:25 AM — “Medical Borders”: a historical perspective. Rakefet Zalashik, PhD (discussant)
11:40 AM — Question & answer period

Anne-Emanuelle Birn opened up the session by commenting on how immigration has always been a critical issue in public health and that focusing on issues of US-Mexican politics, immigration, and public health was especially timely, given the theme of the APHA conference (“Public Health Without Borders”) and its location in San Diego, CA.

Ana Maria Carrillo gave a fascinating presentation, focusing on how Mexico actively engaged with the US over sanitary codes and other aspects of public health and immigration policy during the late 19th and early 20th century. Among the many points raised, one was that whereas the US government (at the federal and state level) repeatedly represented Mexico as a threat to the US, many of Mexico’s epidemics in the early 20th century (e.g., typhus, plague) were imported from the US. Additionally, Mexico was not simply reactive to the US, but instead instigated negotiation over sanitary codes, including via its joining of the American Public Health Association in 1892, so as to have a larger say in US public health policies.

Natalia Molina then covered more recent US-Mexican immigration/border public health issues. Building on her central thesis that immigration and public health policies are profoundly intertwined, she discussed the role of public health in medicalizing borders, with regard to both legal and also symbolic citizenship and inclusion. The three examples she focused on pertained to: (1) Railroad workers in Los Angeles in the early 20th c.; (2) the Bracero program (1942-1964), designed to bring in Mexican laborers to work in the US; and (3) contemporary patient deportations by hospitals of undocumented persons unable to pay for long-term care. As per the prior presentation, a common theme was how Mexicans were depicted by US authorities as a threat, with complete disregard for how Mexicans were badly treated in the US. For example, in the case of the railroad workers, when an outbreak of typhus occurred in the highly congested railroad worker camps, built without adequate sanitary facilities and populated by workers receiving less than a living wage, the US public health authorities waged a campaign premised on the idea that Mexican were “dirty” and needed to be taught hygiene; by contrast, as documented by a letter that Molina cited, the Mexicans argued that what they needed was better housing, better sanitation, and better pay.

The discussant, Rakefet Zalashik, reiterated themes pertaining to the medicalizing of borders, as contrasted to the statement that “disease has no borders.” Among the topics addressed during the lively Q&A period included whether it was appropriate to discuss all of the patient transfers as “deportations,” since some involved actions of only private hospitals or even the Mexican consulate, but not the US government, to which Molina replied that she used the term “medical deportation” to make clear that these events occurred in the context of US immigration policy. Another theme concerned the context-specific racializing of immigration and public health threats, with depictions of Mexicans on the West Coast often different from those of the Japanese, and with concerns about immigration of white “ethnic” groups being more of an East Coast phenomenon than one of the West Coast.

During the Q&A period, questions focused on the use of the language of “medical deportations” (which Molina argued was appropriate, so as to situate health policies in context, especially in relation to immigration policies) and also how issues of “race” and immigration played out differently for diverse groups in the US, e.g., the emphasis in California on persons of Mexican, Japanese, and Chinese origins, with all “whites” lumped into one group, whereas on the US East Coast during this same time period, different “white ethnic” groups were considered separately.

2) POLITICS OF PUBLIC HEALTH DATA
Our thought-provoking session was attended by ≈ 250 people (up from the ≈ 220 in 2007 and 2005, all better than the ≈ 140 in 2006).

ANALYZING HEALTH INEQUITIES: WHAT’S NEW IN THE 160 YEARS SINCE 1848? – APPLYING NEW METHODS TO LONGSTANDING PROBLEMS OF SOCIAL INJUSTICE
MON, OCT 27 ***2:30 PM-4:00 PM (SESSION 3359.0) *** SD CONV. CENTER (SDCC) RM 2
2:30 PM — Introduction to the Politics of Public Health Data session. Catherine Cubbin, PhD
2:35 PM — Using 21st c technologies to analyze the impact of racism on health: the implicit association test (IAT), web-based surveys, and explicit measures of racial discrimination. Nancy Krieger, PhD, Dana Carney PhD, and Mahzarin Banaji, PhD
2:55 PM — Utilizing the CT Health Equity Index, GIS, and community engagement to address health inequities. Baker Salsbury, MPH, MSW, MHSA
3:15 PM — Biological embedding of social factors: epigenetic processes and health inequalities. Darlene Francis, PhD
3:35 PM — Discussant. Vickie Mays, PhD, MSPH
3:45 PM — Question & answer period

Catherine Cubbin opened up the session, introducing the speakers and also the theme of the session – our need to use whatever are the best available methodologies to move forward the work on social justice & public health.

Nancy Krieger presented preliminary research results on novel use of the implicit association test (IAT) to measure experiences of racial discrimination (noting that the IAT has previously been used mainly to study prejudice). In both a community-based sample and a web-based sample of US-born black American adults, the explicit measure of racial discrimination revealed the usual person/group discrimination discrepancy phenomenon (higher reports of discrimination against group than against self), but no such discrepancy was evident using the IAT. Noting that the web-based sample had a much higher education level and better health status than the US black population on average, preliminary findings indicated that among those with less than a college education, both the explicit and implicit measures were significantly associated with hypertension. The implication is that use of both types of measures can advance understanding of how racial discrimination harms health, a hypothe
sis that is now being tested in a large-scale community-based study that Krieger and colleagues currently have underway.

Baker Salsbury presented on the Connecticut Health Equity Index, a public health tool meant to raise accountability at the neighborhood and local level regarding the monitoring of health inequities and efforts to address them, especially by state and local health departments. Developed by the Connecticut Association of Directors of Health, Inc. (CADH), which consists of health directors who represent Connecticut’s 169 towns, including both health departments and districts, the tool draws on public health surveillance data, census data, and myriad other sources of data providing information on social and economic conditions at the census tract level. Using GIS to help map the results, it employs data on a core set of social determinants of health, organized into 9 domains, with 27 components and 71 core indicators, as well as data on diverse health outcomes. Preliminary work conducted in 20 census tracts in two cities in Connecticut has shown expected associations with diverse health outcomes, spanning from mental health emergency room treatment and Hepatitis C infection to cancer incidence rates and age-adjusted mortality rates. Next steps are to test the tool in 800 Connecticut census tracts, with a goal of developing a tool that can be used nationally by communities and local health departments. For more information about the tool, contact Sharon Mierzwa, at CADH (email: smierzwa@cadh.org; phone: 860-727-0974). And see also: http://www.cadh.org/AboutCADH/CurrentProjectsOverview/HealthEquityIndex/tabid/79/Default.aspx

Darlene Francis spoke about why epigenetic processes – that is, processes that regulate gene expression – matter for understanding health inequities. Noting that her work explicitly challenges the dogma that always places genes first, and context second, in shaping phenotype, she offered instead empirical evidence, based on elegant studies of mice, that vulnerable experiences can affect gene expression, thereby affecting phenotype – with the implication being that social and developmental experiences can affect biological vulnerability. As one of the several examples she presented, she discussed one experiment with two different strains of mice – in shorthand, one bred to be “cool, calm, collected” and “smart,” the other much more “anxious” and “less smart.” Noting that fetuses in each breed of mouse would be differently exposed to stress hormones in utero (given that their mothers were likewise either “calm/smart” versus “anxious/less smart”), in her experiment she transplanted the mouse fetuses from one strain to the other, thereby altering their pre-birth exposures, and she also did post-birth swaps, exchanging the different types of pups (those whose full gestation was in their original mother and those who were transplanted to the womb of a mother of the other breed), with some kept with the mother from whom they were born and others places with mothers from the two different breeds. A key finding was the mice whose strain predisposed them to be “anxious/less smart” who were transplanted into the wombs of the “calm/smart” breed mothers and raised by them performed just as well as the mice bred to be “calm/smart” on open-field tests regarding their ability to explore in new environments, thereby demonstrating how context shaping gene expression produces the phenotype (despite these mice being “genetically predisposed” to be “anxious/less-smart”). The net implication is that DNA does NOT equal “destiny” and that epigenetic processes – involving regulation of DNA, not altering changes in the DNA sequence – are likely critical for understanding health inequities.

Vickie Mays, as discussant, emphasized how all three projects worked across disciplines, took risks, and produced data that can give us new insights into causes of health inequities and how to address them. In relation to the Health Equity Index, she underscored the importance of combining data on, say, transportation access with data on where shopping markets are located, noting that in the neighborhood where her mother lived in Chicago, the bus stop was so far away from the shopping market (on the other side of the large parking lot built to accommodate the cars of the shoppers) that it made using the bus for shopping very difficult. Emphasizing the importance of animal studies for investigating topics that cannot be studied on people, she praised Francis’ work for how it powerfully challenged the dominant nature/nurture assumptions by bringing attention to the critical role of gene regulation – and showing how parents’ context can affect health of the next generation through epigenetic mechanisms, not just genetic inheritance. Noting her own research on how the pain experienced as a consequence of racial discrimination and social isolation registers in the brain as the same as that produced by physical pain, she said that use of the IAT was one example of how researchers can use new methods to get at exposure to racial discrimination and its consequences, especially in an era of reduced overt bias. Noting the need to consider the psychological and health costs of people’s reliance on stereotypes, she likewise urged that attention be paid to how IAT results may differ by not only education level but also for persons from more individualistic vs more collective societies. The overall message was that we can use 21st technologies to better understand the mechanisms – at many different levels, from societal to gene regulation – that produce health inequities, and that we need to take risks and ask bold questions to move along the work and make a difference.

During the Q&A, questions focused on whether the IAT can be used to look at voter behavior (yes, it has been, but also key is what happens to the voters, in terms of access to voting, voter exclusion, problems with voting machines, etc), whether the Health Equity Index is intended for national use (yes, but first it needs to be tested in a wider range of census tracts, with the next iteration including 800 census tracts), and whether there is any evidence that damage brought about by epigenetic processes can be reversed (sometimes, depending on the degree of damage and also the rapidity, in early life, that conditions are changed, but some good news is that new evidence indicates the social brain is harder to perturb than has previously been thought, such that there is more resilience and plasticity to give grounds for hope).

3) INTEGRATIVE

This session, celebrating 160 years of the Spirit of 1848, was attended by ≈ 150 people, just about all of whom avidly filled in our ever-present sign-in books. We note that this session was held at the same time slot as the APHA “Town Hall Meeting on Health System Reform,” which, with its emphasis on the current election and post-election planning, was a major draw. (NB: the attendance was very good for an APHA session, albeit understandably less than the ≈ 550 who attended our integrative session last year, which was focused on how to use the new film series “Unnatural Causes: Is Inequality Making Us Sick?”).

160 YEARS OF THE SPIRIT OF 1848: CRITICAL REFLECTIONS, CELEBRATION AND INSPIRATION
MON, OCT 27 ***4:30 PM-6:00 PM (SESSION 3433.0) *** SD CONV. CENTER (SDCC) RM 6C/F
4:30 PM — Introduction: Anne-Emanuelle Birn, MA, ScD
4:35 PM — American Indian, Alaska Native, and Native Hawaiian Caucus; Occupational Health and Safety Section and Labor Caucus; Public Health Nursing Section; International Health Section; Lesbian, Gay, Bisexual, and Transgender Caucus; Black Caucus of Health Workers; School Health Education and Services Section; Socialist Caucus
5:08 PM — Reflecting on the events of 1848: Kirby Randolph, PhD
5:13 PM — Peace Caucus; Family Violence Prevention Forum; Trade and Health Forum; Medical Care Section; Sigerist Circle; Social Work Section; Women’s Caucus; Latino Caucus
5:45 PM — Looking forward, building on the Spirit of 1848: Nancy Krieger, PhD
5:50 PM — EVERYONE: sing “Step by Step,” led by Andrea-Kidd Taylor, DrPH

The full-line up, with names of presenters, is as follows, and the program for and photographs of the event and presenters are available at our website (http://www.Spiritof1848.org), as are several of their slide presentations. We also thank the Spirit of 1848 members who helped out with the event: Pam Waterman, for technical assistance with the music & slides, Catherine Cubbin for keeping the presenters moving along, and Suzanne Christopher and Vanessa Watts for ushering.

Presentation
Musical prelude “Step by Step” and “Ella’s Song”
Spirit of 1848: AE Birn — Introduction
American Indian, Alaska Native, and Native Hawaiian Caucus: Dean Seneca
Occupational Health and Safety Section and Labor Caucus: Peter Dooley
Public Health Nursing Section: Noncenba Lubanga
International Health Section: Samir Banoob
Lesbian, Gay, Bisexual, and Transgender (LGBT) Caucus: Seth Welles
Black Caucus of Health Workers: Jill Dingle
School Health Education and Services: Bill Cissell
Socialist Caucus: Martha Livingston
Spirit of 1848: Kirby Randolph/Lisa Moore – History
Peace Caucus: Kathleen Fagan
Family Violence Prevention Forum: Peggy Goodman
Trade and Health Forum: Susanna Bohme
Medical Care Section: Gordy Schiff
Sigerist Circle: Ted Brown
Social Work Section: Kim Jaffee
Women’s Caucus: Heather Brandt
Latino Caucus: Henry Montes
Spirit of 1848: Nancy Krieger – Closing
Andrea Kidd-Taylor lead everyone in “Step by Step”

Included in the session program are the music and lyric of the song we all sang at the end: “Step by Step,” based on the preamble of the 1863 constitution of the American Mineworkers Association, with the music arranged and adapted in 1948 by Waldemar Hill and Pete Seeger:

Step by step the longest march
Can be won, can be won.
Many stones can form an arch,
Singly none, singly none.
And by union what we will
Can be accomplished still.
Drops of water turn a mill,
Singly none, singly none.

The wide range of presentations – which used song, visual images, and reflected on both the broader social and historical context and the specific work of each APHA caucus, section, and forum that participated – asked all present to think critically about the past 160 years in terms of the struggles and accomplishments we can recognize and celebrate, the setbacks endured and the suffering they have caused and, ultimately, the work we need to do now, in our generation, in our own times, to advance the agenda of social justice and public health.

4) PROGRESSIVE PEDAGOGY

This engaging session was attended by ≈ 100 people (twice the ≈ 50 in 2006, but down from the ≈ 250 in 2007, which drew in many who wanted to know how to teach the content of “Unnatural Causes”).

TEACHING CRITICAL HISTORY OF PUBLIC HEALTH AND HEALTH POLICY: PROGRESSIVE PEDAGOGY IN ACTION
TUES, OCT 28 *** 8:30 AM-10:00 AM (SESSION 4063.0)*** SD CONV. CENTER (SDCC) RM 2
8:30 AM — Introduction. Lisa Dorothy Moore, DrPH and Suzanne Christopher, PhD
8:35 AM — A role for exhibitions: “Making a Difference in Global Health.” Manon Parry, MA MSc
8:50 AM — Literacy, access to information, and social power – 1848 and 2008. Sherry Spence, MD
9:05 AM — Necessity of teaching the history of public health from a critical perspective. John P. Elia, PhD
9:20 AM — University of Toronto’s history of international health course. Anne-Emanuelle Birn, MA, ScD
9:35 AM — Question & answer period

Lisa Moore introduced the session with comments on how the lack of critical teaching about public health history in most US schools of public health was the impetus for the session, since a knowledge of history is part of what enables us not only to better understand the past and how we got to where we are today but also to see ourselves as historical actors who create history in the present by what we do. She also announced that all syllabi discussed in the session will be available at the Spirit of 1848 website, at: http://www.Spiritof1848.org.

Manon Parry described the exhibition the National Library of Medicine launched in April 2008, titled “Against the Odds: Making a Difference in Global Health.” Geared especially to a younger audience and to overcome the widespread views that “global health is about them, not us (in the US),” that “the US provides answers, as opposed to solutions coming from elsewhere,” and that “the problems are so overwhelming that nothing can be done,” the exhibition focuses on “missing stories” about the impact of poverty on health and well-being, the connection between health and human rights, the shared values that promote a decent quality of life, the link of the US to the rest of the world, and concrete examples of individuals, organizations, communities, and societies that have made a difference. Using historical and contemporary examples, the themes of the exhibit pertain to: clean water; nutritious food; access to affordable health care; protection from violence; and safe housing. Other “missing stories” addressed pertain to discrimination and HIV/AIDs, to the spending on monies on conflict and war, rather than health needs. The exhibition goals are to: (1) broaden perception of the causes of illness, i.e., not just viruses but poverty, hunger, and other social determinants of health; (2) challenge assumptions about who is at most risk, looking at inequities within as well as between countries; (3) encourage collaboration based on shared values, e.g., human rights; and (4) encourage people to get involved, especially youth activism. Each week, a new question is placed on a comment board at the end of the exhibition, asking “What’s Your Perspective” and, suggesting the exhibit is meeting its goals, when the question on the board asked “can one person make a difference,” one reply from a student concisely stated: “Hell yeah!” The traveling version of the exhibit is intended to be shown at schools of public health, with the only cost being that of covering its shipment by fed-ex, and the encouraging news is that it is already booked up through summer 2010. If you are interested in having your school host the exhibit, contact Manon Parry at: parrym@mail.nlm.nih.gov; to see more about the exhibit on-line, visit: http://apps.nlm.nih.gov/againsttheodds/index.cfm

Sherry Spence then gave a presentation looking at health literacy and the dissemination of public health information in historical context, with attention to the implications of literacy and health literacy for power relations and health inequities. Examples pertained to the invention and dissemination of use of the printing press in Europe during the Renaissance and Reformation, the rise of slave literacy in the US in the mid-19th century, and the current use of the internet and the importance of e-health literacy. Common themes were the link between literacy and power and the need to build capacity for health literacy, including e-literacy. For more discussion of these issues, and also the 50-page bibliography informing the presentation, see: http://sandbox.wikispaces.com/health-literacy-community

John Elias next presented on a new course at San Francisco State University on the critical history of public health in the United States. Geared to undergraduates, the course’s impetus was the lack of any public health courses focused on history, coupled with the lack of any courses in the history of science department that were focused on either medicine or public health. Approximately 75% of the enrolled students were from public health, the other 25% from history, with one discovery being the utility of pairing up students from these two different disciplines, since the public health students could teach the history students about health, and the history students could teach the public health students about both history and analyzing primary as well as secondary source materials. Key to the course was its inclusion of critical, revisionist history, with an emphasis on the intersections between class, race/ethnicity, gender, and sexuality. Each session includes a 30-35 mini-lecture; other components include: (a) students working in groups to critique, from a critical intersectional standpoint, a particular article, with each student writing a 3-4 page analysis that s/he shares with the other students in the group, as the basis for a joint critique developed by the full group; and (b) engaging the students in critiques of different films, regarding what they cover and what they omit, e.g., a film on the “History of Sex in America in the 20th century,” which, when discussing Margaret Sanger, made no mention of her support for eugenics. There is also a mid-term exam and a final 8-10 page paper. Two aspects of student resistance, both the result of prior educational experiences, that needed to be addressed were: (1) their expectation of being “fed” education rather than be engaged in critical education, and (2) their questioning of the legitimacy of studying history from a historical perspective; by going through the course, students came to appreciate the value of a critical stance.

Anne-Emanuelle Birn described the graduated level course she teaches, a seminar on the History of International Health at the University of Toronto. This course looks at the ideologies, institutions and practices of the field of international health, from its imperial origins to the present-day, including in relation to colonialism, class, racism, and gender. Focusing on the political, scientific, and social underpinnings of the principles and activities of the international health field and its embedded cultural values as well as both its continuities and discontinuities, the course relies on both primary sources (e.g., printed documents, whether text, correspondence, or poems, and also photographs and films) and secondary sources (e.g., scholarly research, both books and articles). Each session uses films and documentaries and draws especially on the visual resources available at the National Library of Medicine (with Anne-Emanuelle also acknowledging the work of Elizabeth Fee, who was present in the audience, for her essential work in making more visible and available critical work on the history of public health). The two assignments are: (1) from the perspective of a late 19th or early 20th century medical officer, justify the importance of a particular international health activity or policy, and (2) write a 2050 paper, analyzing early 21st century work in international health, so as to learn how to contextualize the on-going work in one’s own era. Examples of themes of particular sessions are: (a) Colonial vs International vs Global Health: what’s the difference?; (b) Mind, Body, Race, and the Building of Empire; (c) Missionaries and Health; (d) Industry, Research, and “Tropical” Medicine; and (e) Sex, Sickness, and Security: Metropole and Outpost. Examples of two contrasting films, whose use sparks lots of conversation among the students, are an mid-20th century American Medical Association film titled “MD International” (1958), featuring then Vice-President Richard Nixon extolling US efforts to help others abroad, versus a very different, sponsored by the World Health Organization, on “Health for All” (1978), made after the Alma Ata conference, and showing footage of, among other things, a Frelimo rally in Mozambique, making clear how the fight for national liberation was essential for health, with health campaigns to fight disease, conducted in the midst of armed struggle, portrayed as part of a strategy to ensure people would be strong enough to build their nation – and with contemporary students amazed that WHO would ever have included such material in a film, noting how in the current era, prevailing ideologies and power relations have precluded such a critical stance.

Suzanne Christopher then opened up the session for Q&A, noting how the presentations had made vividly clear how many “missing stories” there were and why a critical historical perspective is needed. From the floor, Elizabeth Fee underscored the many resources that are available at the National Library of Medicine, including not only films but also syllabi of courses taught world-wide about the history of public health and medicine, and noted that the NLH is currently producing a DVD-series to make the films more widely available. For these and related resources, see:
– for films: http://www.celebratingresearch.org/libraries/nlm/healthfilms.shtml
– for syllabi: http://www.nlm.nih.gov/hmd/collections/digital/syllabi/index.html
An additional resource mentioned by Walter Lear is the US Left Health Historical Center, based in the Institute of Social Medicine and Community Health (in Philadelphia) which he directs and whose website is in construction. The Center has available archival documents (e.g., pamphlets, photographs, political pins) and scholarly publications and also produces a news letter; for further information, contact Walter Lear at: ISMCH, 206 N. 35th St, Philadelphia, PA 19104 (phone: 215-386-5327; email: wjlear@critpath.org). Other issues raised during the Q&A period included how to ensure these sorts of courses are taught, or materials are at least included in required introductory courses, given how many other requirements students face, and also how to ensure that whatever is included as session in other courses is presented in a critical way (e.g., simply including photographs of the Broad Street pump and mentioning John Snow is not adequate for critical history of epidemiology) and how to address the problem that most students need remedial education in general history so as to put the public health history in context – with the only way to address this being that there is no short cut around the fact that students do have to read to gain this context …

5) STUDENT POSTER SESSION
Our 7th “STUDENT POSTER SESSION: SOCIAL JUSTICE AND PUBLIC HEALTH” (session 4099.0, Tues, Oct 28, 12:30 to 1:30 pm) had 6 posters accepted (of which 1 had to withdraw). There was a good turn out, with lots of good discussion with the student presenters about their work. The five posters displayed were as follows:
STUDENT POSTER SESSION: SOCIAL JUSTICE & PUBLIC HEALTH
TUES, NOV 7 *** 12:30 -1:30 PM (SESSION 4099.0)*** BOSTON CONV. CNTR (BCEC) HALLS A/B1
Board 1 — Invisible Places, Invisible People: Facing health disparities in urban North Carolina K. Wu, MPH Candidate; J. Kadis, MPH Candidate; C. Katz, MPH Candidate; K. MacGuire, MPH Candidate; A. Agyemang, MPH Candidate
Board 2 — Other side of the tracks: Understanding the historical, social and environmental context of health in an African American community in eastern North Carolina S. Barber, MPH Candidate; J. Tzeng, MPH Candidate; A. George, MPH Candidate; J. Thompson, MPH Candidate.
Board 3 — Interdisciplinary approaches: A student-initiated course on Critical Race Theory J. J. García, MPH.
Board 4 — Goods Movement 101: A training model for community engagement and education J. Lucky, MPH; A. Logan; A. M. Hricko, MPH; I. Ramirez; C. Truax; A. J. Groopman, MHS.
Board 5 — A gender analysis of cervical cancer R. M. Lee

Of note, for all the students involved, their poster presentation at the Spirit of 1848 session was the first time they had ever presented a poster at a scientific conference, and for virtually all it was their first time attending an American Public Health Association annual meeting. They really appreciated the opportunity to gain the experience of presenting their work and meeting so many different people in so many diverse aspects of public health, and likewise felt affirmed in their focus on issues of social justice and public health. All of which suggests our session is meeting its objective, in helping bring forward the next generation to do the work at hand!

6) Other:

We co-sponsored & helped organize the P. Ellen Parsons Memorial Session, on “Health Access & The Elections: What Happened, What Didn’t” (Session 4242.0, Tues, Nov 7, 2:30 to 4:00 pm), obviously held before the elections (and we are now very happy to send our reportback in the aftermath of the Obama victory!). The primary sponsor was the Medical Care Section; other co-sponsors were the Women’s Caucus and the Socialist Caucus. It was attended by ≈ 100 people (up from ≈ 75 people the year before, and much higher than the ≈ 35 in 2006).

• Ellen Shaffer opened the session by reviewing and contrasting the Obama and McCain health plans and their limitations, noting that HR676 in Congress still was putting forth support for a universal single-payer health system and that people in public health need to keep alive support this alternative and sorely needed approach to resolving the problems of the US medical care system.
• Claudia Fegan, the past president of the Physicians for a National Health Program (see: http://www.pnhp.org), then made the case for why a single-payer universal health system is necessary, including a review of all the US state-level plans that have promised to provide universal coverage but have not succeeded, given their approach of only incremental reform (leading her to quote Moms Mabley: “if you always do what you always did, you always get what you always got …”).
• Susan Wood, an advisor to the Hilary Clinton and now the Obama campaign, then spoke to how each candidate’s plan did or did not address women’s health needs, noting that the Obama plan opened the door to people “voting with their feet” for single-payer via signing up for a group insurance plan modeled after Medicare and the Federal employees benefit plan, whereas the McCain approach was to have people cut loose from employer-based plans and opt for individual plans, even though evidence indicates women fare much worse under individual-plans, where they are more underinsured than men and everyone is much less able to negotiate, as an individual, for better plans. Her sense is that the Obama plan was cautious so as not re-ignite the fears caused by the “Harry & Louise”-type ads that sunk the prior Clinton attempt at health care reform, and said that advocates need to ensure that the Obama plan, if he is elected, is the floor, not the ceiling.
• Larry Adelman then spoke about the efforts of the film series “Unnatural Causes” (see: http://www.unnaturalcauses.org/) to get across the message that action is needed on the social determinants of health. So far, there have been over 10,000 screenings and they have more than 350 outreach partners, far more than expected, and remain engaged in a Health Equity Campaign whose goals are to educate the broader public about the root causes of health inequities, to inject the issue of social determinants of health into public debate, and to highlight the health consequences of economic policy. Four key message frames are: (1) focus on the social determinants of health equity (e.g., it takes more than individual choice to deal with toxic dumps, ensure a living wage, or have available affordable quality housing); (2) make health equity an “us” issue (vis a vis the social gradient and rising health care costs); (3) America’s health is America’s choice (demonstrating that health inequities are neither natural or inevitable, cf studies by Singh et al showing how health inequities have widened since 1980, and the 2008 PlosMed study by Krieger showing how health inequities in fact shrank between 1965 and 1980 and thereafter widened, with the progress in shrinking the inequities paralleling the implementation of the War on Poverty, the Civil Rights Act, the creation of OSHA and EPA, etc.); and (4) Common sense: invest now for better health or pay even more later to repair the damage.
• Linda Rae Murray, as discussant, then spoke to the importance of not staying stuck in an overly complicated policy-wonk mode but instead appealing to people’s sense of fairness, framing health care as a human right, and making clear the current system does not work and incremental efforts at reform have made little or no difference. She also emphasized that one reason that efforts over the past 100 years have failed is that creating a system that fairly provides universal health coverage is a way of redistributing wealth, which goes against capitalist ideology, such that it requires taking this ideology head-on, noting that especially in this time of economic crisis, many people would agree that the “invisible hand of the market” is not an “all-knowing god.” Arguing that we can point to how every other industrialized capitalist country has managed to ensure universal medical coverage, she further noted that this is only one piece, since good health is only possible in a just society, meaning that we need to bring in allies to address the broader social determinants of health.

During the Q&A, a key theme was that health advocates cannot afford to repeat past mistakes, e.g., diluting proposals in order to be “allowed at the table” or directing work only towards policy makers; it is vital to work with the people & public more generally, since they are the source of power and do want universal health coverage and better health.

Finally, the Spirit of 1848 co-sponsored the Occupational Health and Safety health activist dance on the Monday night of APHA.

Posted by Matt Anderson, MD