Archive for the 'Critical Social Medicine' Category
3 Comments February 16th, 2009 by Matthew Anderson
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:
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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:
- 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.
- “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.”
- 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
1 Comment December 6th, 2008 by Matthew Anderson
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
1 Comment November 10th, 2008 by Matthew Anderson
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
2 Comments October 19th, 2008 by Matthew Anderson
Last week saw the release of the second Global Health Watch report, created as an alternative to the WHO’s World Health Report. It is an initiative coordinated by the People’s Health Movement, the Global Equity Gauge Alliance and Medact with input from 80 organisations and more than 130 individuals. It presents a progressive agenda for global health. A sixteen page overview of the report can be downloaded here.
The Global Health Watch is important for several reasons. First, it provides a radical critique of the existing model of “global health” which is dominated by neoliberalism and a subservience to corporate interests. Secondly, it is a truly international critique which draws on the resources and experiences of academics, activists, and social movements throughout the world. This is a report born with a democratic spirit. Finally, in this international call to realize the vision of Alma Ata, we are reminded that another world is possible. Indeed, the very creation of the report shows us that there is a broad movement to create that other world. This is good news.
From the Press Release:
Alternative world health report calls for radical change
Civil society organizations and scientists from around the world are calling for ‘a new development paradigm’ to address the toxic combination of climate change, growing poverty and inequality and poor health.
The new report, Global Health Watch 2, says that unfair social and economic policies combined with bad politics are to blame for the poor state of the health of millions of people in the world. The report makes stinging criticisms of key global actors, including the World Health Organization, the World Bank and the Gates Foundation. The report calls on governments to stop the Bank from meddling in health politics.
Global Health Watch 2 provides examples of civil society mobilization across the world for more equitable health care and more health promotion, although more is needed to bring about significant improvements in health.
The report reveals widespread unease about the immense but unaccountable power and influence of the Gates Foundation. It says that although the Gates Foundation has injected vast sums of money into global health, it operates in an undemocratic way and reinforces a medical-technical approach.
Among other issues it highlights is the pressure exerted on the World Health Organization by powerful and vested interests that would prefer WHO’s activities and programme to have a more biomedical and less political focus.
The first edition of Global Health Watch, published in 2005, was hailed for its ground-breaking analysis and mobilising call to action.
Marion Birch, director of the London-based charity, Medact:
“Priorities set by the rich world damage the health of people thousands of miles away. Funding for water and sanitation is falling while slum-dwellers in Lagos pay up to 40 times as much for water as residents in downtown New York. Oil extraction in the Niger Delta generates billions of dollars of revenue but local communities lack basic health care.”
Amit Sengupta of the People’s Health Movement in India:
“The World Bank’s job is to help transfer resources from richer to poor countries and it should act accordingly. Its impact on the health systems of poor countries has been largely negative. Internationally, it has also contributed to the uncoordinated circus of health sector policy-making that makes it difficult for Ministries of Health to function”.
Martin Drewry, director of the charity Health Unlimited:
“The majority world does not want charity – it wants a fairer political and economic system. It needs fewer billionaires; not more. While it is great that Bill Gates is willing to donate his money towards improving health in Africa, he would do far better campaigning for more effective tax systems both nationally and internationally”.
Posted by Matt Anderson
Add a comment October 3rd, 2008 by Matthew Anderson
We have just published the 10th edition of Social Medicine/Medicina Social, our bilingual, online journal. It is available in both English and Spanish.
Editorial
Social Medicine/Medicina Social’s 10th Issue, The Editors: Our brief reflections on the progress and problems of publishing an online journal. With many thanks to those of have helped us.
Original Research
Maquila Workers’ Health: Basic Issues, What is Known, and a Pilot Study in Nicaragua Lylliam Perpetuo López, Luis Blanco R., Aurora Aragón B., Timo Partanen: Trying to assess the health impact of the maquila industry and how best to study it.
Themes and Debates
Health Equity: Conceptual Models, Essential Aspects and the Perspective of Collective Health Nivaldo Linares-Péreza, Oliva López-Arellano: An attempt to review the state of the literature using the critical lens of collective health.
Social Medicine in Practice
Experiences in Popular Education in Sandinista Nicaragaua, Maria Felisa Lemus: Midwives, vaccination campaigns, the contra war, and Ben Linder riding a unicycle in Sandinista Nicaragua
News & Events
International Seminar of Public Health Policy Asuncion, Paraguay International Seminar of Public Health: A Paraguayan perspective on the right to health.
A Social Medicine Perspective on Gender-based Health Inequities: Defending the right to sexual and reproductive choice in Chile, Mario Parada Lezcano, Paula Santana Nazarit: The Chilean social medicine community reacts to a recent Constitutional Court decision prohibiting the provision of emergency contraception by public institutions.
Latin American Association of Social Medicine (ALAMES) XI Congress, November 17-21, 2009, Bogota, Colombia Mauricio Torres Tovar: This conference will mark the 25th Anniversary of ALAMES. What role does health play in the larger social and political agenda? How can the social medicine community join forces with others to promote the right to health?
Add a comment September 24th, 2008 by Matthew Anderson
Cara Muhlhahn, Certified Nurse Midwife (left) with Mayra and David Radzinski. Photo Credit: Paulo Netto
Social Medicine Rounds on 9/23/08 was devoted to a showing of the film The Business of Being Born, produced by Ricki Lane and directed by Abby Epstein.
The film, which traces several pregnancies and births, offers an extended contrast between the highly medicalized world of US obstetrics and the world of homebirths and midwifery. It argues that American medicine has so lost touch with the basic needs of women in labor that most obstetricians have never seen a home birth and only rarely witness a ‘normal’ birth.
In 1900, 95% of birth in the US occurred in homes. Fifty-five years later less than 1% did. During this time, physicians asserted control over pregnancy and birth, progressively marginalizing midwifery. With the introduction of fetal monitors in 1970, Cesarean Section rates in the US climbed from 4% of births to 23% in the space of a decade. This dramatic change in medical practice occurred without evidence to support the benefit of fetal monitoring. The film argues that hospitals and physicians, anxious to keep the assembly line of the obstetrics floor moving smoothly, simply don’t have time for normal labor. Women are started on epidurals for pain, their labors slow, they are given pitocin to augment contractions, they get more pain, more pain medicine, more pitocin, and so on in a cycle of ever increasing medical intervention. “Her labor is taking longer than it should,” is the comment of the obstetrician. Finally when the monitor shows fetal distress, the doctor intervenes “for the sake of the baby.” The woman ends up with a Cesarean, the safest solution, we are told, for the doctor concerned about malpractice.
Woven into this story is the counter tale of how home birth was revived by the hippies during the 1960′s. Ina Mae Gaskin, the “mother of authentic midwifery” is interviewed and we see scenes of her working at the Farm Birthing Center. She proudly recounts that they did not do their first Cesarean until after over 180 births. The film also follows a contemporary certified nurse midwife (seen in the photo above) as she rounds in New York City. We witness several home births – including that of Ricki Lane. These are clearly the most striking moments of the movie. The women labor in a variety of positions – squatting down, lying in a tub, squatting in a tub, lying propped on a couch. In an amusing moment a Brazilian doctor describes how the lithotomy position (lying flat on your back with your feet up) is the worst possible one for a woman delivering a baby. Finally, after the intense pain of labor, there is a moment of silent release and the baby is born. “Reach down and take your baby,” the midwife says to the new mother. As a physician who has experienced only hospital births these scenes were revelatory.
Running throughout the film is a concern over the safety of homebirth and the competence of midwives. And not all of the home births shown are successful. But if one can question homebirths and midwifery, is it not also legitimate to question hospital births and the competence of physicians? Clearly, 1/3 of all births don’t have to be done by Cesarean Section. The question really is how to design a health care system that can find the right place for each type of practice. But academic medicine seems largely unable to even pose that question.
Our thanks to the filmmakers for posing it so movingly. And for allowing us to share in the births of their children.
The film’s website has links to a variety of resources on midwifery and a short trailer.
Posted by Matt Anderson, MD
Add a comment August 11th, 2008 by Matthew Anderson
In preparation for the upcoming World Congress of Epidemiology in Porto Alegre, Brazil, the August 2008 edition of the International Journal of Epidemiology is devoted to Latin America. Two articles, in particular, are relevant to those of us with an interest in social medicine:
Howard Waitzkin, Celia Iriart, Holly Shipp Buchanan, Francisco Mercado, Jonathan Tregear, and Jonathan Eldredge discuss the Latin American Social Medicine Database run at the University of New Mexico. This is a database about which we have posted previously.
Jaime Breilh, one of the most important figures in Latin American Social Medicine, describes a vision of Latin America’s critical, social epidemiology as a means to “confront the menacing forces producing our unhealthy societies and an opportunity to form fraternal partnerships on the intercultural road to a better world, where only an epidemiology of dignity and happiness will make sense.”
At the time of this posting, the full articles were not available for free on-line. The Journal offers free excerpts (both of which follow). Interested readers may want to contact the authors for reprints. You can email them through these links: Dr. Howard Waitzkin, Dr. Jaime Breilh.
The Latin American Social Medicine Database: a resource for epidemiology
Latin American social medicine (LASM) has become a widely respected and influential field of research, teaching and clinical practice, yet its accomplishments remain little known in the English-speaking and -reading world.1-3 Important publications have not been translated from Spanish and Portuguese into English, and the majority of LASM journals are not indexed in MEDLINE or similar bibliographic databases. The field’s development also suffers from technical difficulties of publication and distribution within Latin America.
In LASM, a perspective emphasizing the social origins of illness and early death has focused on sources of these problems in relations of economic and political power. This orientation has contributed to the analysis of inequity in health and to alternative proposals for change. For instance, LASM analyses critically some of the dominant reform strategies in public health systems, offers proposals for alternative health policies and fosters research on the micro- and macro-political processes that affect health . . . [Full Text of this Article]
Latin American critical (‘Social’) epidemiology: new settings for an old dream
Background: Epidemiology’s role as the ‘diagnostic’ arm of public health has submitted epidemiological reasoning and practice to the crossfire of and demands. In Latin America, the visible signs oppositional social values of extreme social and political authoritarianism and inequity, as well as the growing unfairness of the World economy, inspired a culture of social critique and a corresponding academic reform movement, which nurtured a profound social awareness among health scientists.
Aims The authors’ aim is to call attention to the need to overcome this scientific North/South divide. An imperative, at a moment when the demolition of health standards under the pressures of global economic acceleration and ‘unhealthy health policies,’ confront us all with the common challenge of cross-fertilizing the strengths of academic traditions from both South and North.
Methods The present paper offers a fresh perspective from the South about the relevance of progressive Latin American public health (termed ‘collective health’) by highlighting a number of its hard scientific contributions which, unfortunately, remain almost unknown to mainstream medical and public health researchers outside Latin America.
Results An armed form of structural greed has now placed the world on the brink of destruction. At the same time, however, fresh winds blow in the continent.
Conclusion This paper is an invitation to confront the menacing forces producing our unhealthy societies and an opportunity to form fraternal partnerships on the intercultural road to a better world, where only an epidemiology of dignity and happiness will make sense. [Link to the article]
Posted by Matt Anderson
1 Comment June 7th, 2008 by Matthew Anderson
Direct to consumer advertising (DTCA) of prescription medications is a relatively new and controversial marketing practice. Public health researchers and sociologists are beginning to explore the possible impact of these marketing practices on the epidemiology of some diseases. Is it possible that this marketing strategy propels the social construction of targeted disorders, like depression? For example, advertisements bring attention to specific symptoms (i.e., loss of interest or pleasure) and encourage consumers to label such symptoms as a disease (i.e., depression). Furthermore, is it possible that this approach to disorder construction has profound implications for public health? Advertisements stimulate the rapid uptake of new medications that may have unforeseen harmful effects and have targeted a specific audience that perpetuates disparities in access to care.
Web Resources:
Healthy Skepticism, one of the best sites for critical thinking on the pharmaceutical industry offers an extensive bibliography concerning DTCA on their website.
Disease mongering by the pharmaceutical industry has received a good deal of attention over the past few years. Lynn Payer’s Disease-Mongers: How Doctors, Drug Companies, and Insurers are Making You Feel Sick is a clear and passionate critique of how the “medical industrial complex” makes healthy people sick. A shorter introduction can be found in the 2004 article by Ray Moynihan, Iona Heath and David Henry’s article, Selling Sickness: The Pharmaceutical Industry and Disease Mongering, (British Medical Journal, April 13, 2004). A more recent collection of articles on the topic is listed on Anne T.-V’s blog.
For a look at DTCA related to Irritable Bowl Syndrome and women’s health see the Our Bodies Ourselves website.
DTC Perspectives, a pharmaceutical trade journal provides the industry point of view on DTC. The journal can be downloaded for free and makes very interesting reading.
The Center for Drug Evaluation and Research site for FDA has survey results related to DTCA.
1 Comment April 26th, 2008 by Matthew Anderson
Under the banner “Just Say No to Drug Reps” the No Free Lunch campaign challenges doctors to give up their dependency on drug companies.
The site uses a alcoholism motif, beginning with a modified CAGE screening test:
- Have you ever prescribed Celebrex?
- Annoyed by people who complain about lunches & free gifts?
- Is there a medication loGo on the pen you are using right now?
- Do you drink your morning Eye-opener out of a Lipitor coffee mug?
Two or more “yes” answers may indicate a problem. But fortunately the campaign can help you with your dependence problem. Visitors can take a pledge to abstain from accepting gifts from drug companies and be listed on a “drug free doctor” database. There is even a “pen amnesty”!
No Free Lunch is the brainchild of Dr. Bob Goodman, a New York internist. Among the other resources on the site are:
So, it’s really not all that complicated to deal with drug representatives. Just say no.
