Silos, Streams, and Social Justice

Dr. Adewale Troutman discussing the stream
analogy at the CPH. 

A highly-regarded professor in the Department of Community and Behavioral Health tells each of her students that engaging in a reflective process is one of the most important practices you can do as a public health professional. Well...it is now officially post-graduation time and I am finding myself reflecting on my transformation over the past two years. As I prepare to take my next steps out into the world of public health practice, I am thoughtfully considering the lessons I have learned and how I can apply those lessons every day for the rest of my career. 

Last week, I was privileged to attend a lecture by Dr. Adewale Troutman, past president of the American Public Health Association. His presentation, entitled “Health Equity: Moving from Theory to Action, Taking it from the Textbook to the Street,” was inspiring to me as a young professional about to take what I learned in graduate school and apply it to the streets of Detroit, Michigan. There were three themes that resonated with me throughout his speech, all of which were woven throughout the curriculum and my practical experiences at the University of Iowa College of Public Health.

Silos

The first theme that Dr. Troutman talked about was this idea of silos and how we can begin to break down the barriers between research and practice, academia and community organizations, and public health and medicine. As someone who is starting the next step of my journey in the world of medicine, I hope that I can teach my fellow classmates to move beyond the medical model of health and to examine the multitude of factors that may be affecting their patients' health at the individual, interpersonal, organizational, community and policy level (socioecological model, anyone?). It is my greatest wish that we as professionals can begin to break down these silos and start playing nicely in the sandbox. Collaboration is a valuable tool. I have found in my LEND training that interdisciplinary evaluation and discussion of a problem (whether it be a single client or a state-wide system) is the most effective and efficient way to achieve a positive outcome. The health problems that our future generations will face are complex. It will require a diversified skill set and many different perspectives to ensure that we achieve the goal set by Dr. Troutman and APHA: to close the gap in health [income, education, access to care...] in one generation. 

Streams

The next theme that was discussed was the idea of moving upstream, from treatment of disease to prevention and promotion of overall health and well-being. Dr. Troutman used the stream analogy in a way that I thought was very thought provoking. He said that there are four places in which to focus our efforts - all of which are necessary but no single one is sufficient. First, we can move upstream and focus on the root sources of disease and excess death (e.g. social determinants, racism). I read an recent article about how there is a growing movement of "upstreamist" doctors who are no longer satisfied with simply giving a drug to manage disease. It is encouraging to see physicians working with public health to try to change the environment for their patients. The second place in which we can focus our efforts is to 'teach them how to swim,' meaning helping communities gain the skills to self-create a healthy environment to live, work, and play. Community-engagement and research that is participatory and community-based is a great way to start this process. Third, we need to continue to help people drowning downstream and to do our best to treat individuals facing disease, help those living in poor conditions, and prevent excess death. Finally, we need someone overseeing and coordinating all of these efforts to ensure that research is applied and that we are seeing both the forest and the trees. 

Social Justice

The final - and arguably most important theme - that Dr. Troutman discussed in his lecture is social justice. The definition of social justice is that all people deserve equal access to societal power, goods, and services. This implies that all people deserve the opportunity for optimal health and that health is a basic human right and a matter of human dignity. Our job is to make the systems fair and accessible for all. Troutman also talked about changing the rhetoric in which we as public health practitioners talk about social justice - moving from understanding health disparities (differences that exist) to advocating for health equity. Today, health status is based on so many factors: race, socioeconomic status, disability status, and even zip code. There are even implicit provider biases and attitudes that impact how health care is delivered. In order to wholly practice the idea of social justice, there needs to be a paradigm shift to a mentality that is, at its core, human-centic. As Troutman said in his lecture "There is no 'them' - only 'us'."

As my time in the MPH program comes to a close, I am left with two overwhelming feelings: apprehension and empowerment. I am nervous about how much I can really do to help communities and families - after all I am just one person. I worry about the stressful environment that children are being born into and the growing list of determinants that will affect their health throughout the lifespan. However, I also feel empowered and I refuse to let these challenges deter me from trying. I will continue to spread the word about public health in order to create a collective consciousness about the issues. I will continue to focus my efforts on early intervention and helping kids get off to a healthy start in life. I will continue to collaborate with my classmates (now colleagues) who remain in the world of public health and other health disciplines.

My first blog post talked about diving in head first to something that scares me. At least now I know that I am prepared to enter the waters of public health with the tools and life supports to stay afloat. Thank you for reading.

Selfie at graduation with Dr. Parker (our Department Head) and Dr. Woods-Jaeger.

The Power to Protect

PSA from the American Academy of Pediatrics

In honor of National Infant Immunization Week and the recent media coverage on the measles outbreaks, I thought I would write a short post about the POWER OF VACCINES. As someone who believes in protecting our most vulnerable population - children - it seems like a no brainer that parents in the developed world would choose to vaccinate their children. However, as we learn in our health behavior courses, vaccination is a complex behavior. It depends on parents' perceived susceptibility of their child getting the disease, the perceived severity of the disease itself, and the real or perceived costs and benefits of vaccination (our old friend, the Health Belief Model). Oh, and cues to action like this lovely public service announcement!

According to the Centers for Disease Control and Prevention (CDC), we have reached several significant milestones related to vaccine-preventable diseases:

• Through immunization, we can now protect infants and children from 14 vaccine-preventable disease before age two.
• In the 1950s, nearly every child develop measles, and unfortunately, some even died from this serious disease. Today, few physicians just out of medical school will ever see a case of measles during their careers.*
• Routine childhood immunization in one birth cohort prevents about 20 million cases of disease and about 42,000 deaths. It also saves about $13.5 billion in direct costs.

*However, as many of you have read in the news recently, measles is now worrisome reality in the U.S. Since the new year, measles has infected 129 people in 13 states, the most in the first four months of any year since 1996 (CDC officials). So what's the culprit? I am sure there is a multitude of complex factors leading up to this outbreak, but perhaps a lack of herd immunity (due to low vaccination rates) is part of the problem.

Everything you need to know about vaccines by German Lopez

Herd immunity is "when a critical portion of a community is immunized against a contagious disease, most members of the community are protected against that disease because there is little opportunity for an outbreak. Even those who are not eligible for certain vaccines—such as young infants, pregnant women, or immunocompromised individuals—get some protection because the spread of contagious disease is contained." (vaccines.gov). The infographic on the left is helpful in understanding this concept. 

So how do we protect again future measles outbreaks? Measles can be prevented by just two shots of the combination MMR (measles, mumps, and rubella) vaccine. There is even a helpful vaccine schedule for parents to help keep them all straight! 

There is a paradox that we learn about in the MPH program that says "when public health works, nothing happens." Universal immunizations for children is one of the Top Ten Public Health Achievements of the 20th Century. It is my sincere hope that the popular press and pervasive myths of the 21st century do not unravel all the hard work that public health has done to protect our most vulnerable populations from communicable diseases.

Making Change Happen on Capitol Hill

"Don't just throw pillows at your television. Engage to make a change!" (staff person for Senator Grassley)

Cherry blossoms were blooming at our nation's capital!

Disability advocates, myself, and several interdisciplinary LEND (Leadership Education in Neurodevelopmental and Related Disabilities) Trainees and from across the country came together last week for the annual Disability Policy Seminar held in Washington, D.C. At the Disability Policy Seminar, attendees were armed with the information needed to help educate our Members of Congress and their staff on the priorities of the ID/DD community. One of the most important lessons that we as young professionals learned from the Seminar and Hill Visits was the importance of engaging with the legislative process in order to create change for individuals with disabilities. As a current LEND trainee in the field of public health, I was impressed with the collaboration between multiple organizations (American Association on Intellectual and Developmental Disabilities, The Arc, Association of University Centers of Disabilities, National Associations of Councils on Developmental Disabilities, Self Advocates Becoming Empowered, and United Cerebral Palsy). It is rare to see so many groups with differing missions come together to work towards a common goal and bring a united front when working on key policy issues.

The opening presentation entitled Forging a Path Toward Bipartisanship featured such notable panelists as former U.S. Senator Pete Domenici, Former U.S. Representative Tony Coelho, and several staff members from the Bipartisan Policy Center. This session highlighted the importance of using commonalities and personal stories to get things done in Congress. The panelist also stressed how vital it is to identify new disability champions in both parties, especially with all the new faces in Congress. With several important pieces of legislation coming down the pipeline, such as the ABLE Act and Combatting Autism Reauthorization Act, it has never been more important to advocate in a bipartisan manner. In addition, we learned that future legislation, which hopes to garner bipartisan support, should be developed in a bipartisan manner.

Iowa LEND trainees with disability and public health
champion, Senator Tom Harkin. 

Another highlight of the conference was hearing from the speakers representing Self Advocates Becoming Empowered - their slogan is "nothing about us, without us." In particular, Claudia Gordon, who served as the liaison between the disability community and the Obama Administration, delivered an inspiring speech (through sign language) that made each person in the audience feel like they could make a difference as an advocate. The seminar left LEND trainees feeling prepared and energized for the Capitol Hill Visits on Wednesday. For many of us, this was our first time advocating for something we each care deeply about – the Combatting Autism Act (which funds our wonderful program). After meeting with the staff of Senators Harkin and Grassley, we were surprised by how accessible the whole process was and encouraged by the fact that each of our voices were heard and taken seriously. LEND is all about becoming leaders, not only in our disciplines, but also in the communities that we serve. The Disability Policy Seminar empowered each of us to take on this role as future leaders in healthcare.

Mental health is public health, too

This blog post was written and created by Elizabeth Golembiewski (guest blogger) - MPH in Health Communication student. 

“Is there no way out of the mind?” 

― Sylvia Plath

Like many people, I grew up thinking that public health was all about Hazmat suits and virus hunters and making sure the water was safe to drink. Not so! As we in the MPH program have the pleasure and also the pain—when it comes to narrowing our focus for papers or our practicum, that is—of knowing, you can argue that pretty much ANYTHING is related to public health!

But where does mental health fit in?? As both a risk factor for and an outcome of other somatic disorders, mental illness is a complicated matter. Public health interventions often are easiest when the problem is highly preventable and has a direct causal root—a paradigm that mental illness, given its blend of genetic, biochemical, psychological, and environmental risk factors, certainly does not fit.

But just like socioeconomic status, poor mental health has a pervasive influence on many other health outcomes. Research has demonstrated a relationship between mental illness and adverse health effects and behaviors such as hypertension, cardiovascular disease, physical inactivity, and tobacco use-- to name a few. 

Mental illness is also common. According to the National Institute of Mental Health (NIMH), our country’s foremost public agency for mental health research, around 20% of adults in United States have a diagnosable mental illness in a given year. Look around you the next time you’re sitting in class, or riding the Cambus—that’s one in five people who have experienced mental illness of one kind or another.

As with many other issues in public health, treatment for most mental health disorders is effective and available. However, most people who meet the criteria for a mental illness will not receive treatment for it. The reasons for this are numerous—factors such as lack of insurance coverage, the belief that symptoms will go away on their own, and stigma all contribute to this problem. 

Fortunately, public health efforts have recently begun to recognize mental illness as an issue that requires attention. According to the CDC, the challenges in this area for public health are to “identify risk factors, increase awareness about mental disorders and the effectiveness of treatment, remove the stigma associated with receiving treatment, eliminate health disparities, and improve access to mental health services for all persons, particularly among populations that are disproportionately affected.” 

At an individual level, you can start by taking the time to learn more about different mental illnesses, their prevalence and risk factors, and reading personal accounts of those who have lived with mental illness. I volunteer with our local chapter of the National Alliance on Mental Illness (NAMI), a wonderful organization that does advocacy at the local, state and national levels—consider checking out their website for resources and information.

Guest Blogger: Hungry Planet

This blog post was written and created by Ann DePriest - a peer in the Community and Behavioral Health Department. 

It’s pretty common to see pictures of food scattered throughout social media. How many of us haven’t posted a picture of a meal we’ve eaten at a restaurant or made ourselves? Photographer Peter Menzel took this practice to a new level through his project “Hungry Planet,” a documentation of food consumption around the world. Menzel traveled across the globe, photographing what an average family purchases for groceries in a given week and how much they are spending on those foods.  

Flip through the slideshow here: http://world.time.com/2013/09/20/hungry-planet-what-the-world-eats/

It’s interesting to scroll through the images and see the differences in what people purchase. You see much more fresh food in countries like Egypt, Mexico, Turkey, and Guatemala. Mali, Bhutan, Ecuador, and Chad have diets that are much more grain based. The more industrialized nations, such as the United States, Germany, Great Britain, and France, feature more boxed or canned foods and premade meals. The costs vary as well. They range from $1.23/week in Chad all the way up to $731.71/week in Norway.

Food availability can depend on location, means, and what we consider to be “healthy.” This availability, through the concept of food security, has frequently been cited as a priority global health issue, especially in developing countries and as a way of creating sustainable development. The World Health Organization defines food security as “including both access to food that meets people’s dietary needs as well as their food preferences.” Food security is about much more than just having access to nutritious foods. It also takes into account if these foods are available consistently and if a person has sufficient knowledge to use them.

Although many developing countries are often identified as being food insecure, every nationality and culture has its own views on food. In our class on Designing and Implementing Interventions, we have talked a lot about the concepts of cultural humility and cultural competency. As public health practitioners, it is important to set aside our personal values and beliefs and have the cultural competency to understand these views when working with different populations about nutrition, especially when it comes to food availability.

Along with culture, it’s also interesting to think about how environment can influence the things we eat. In Community and Behavioral Health, we talk a lot about the environment as a determinant to health and well-being. Menzel’s project will be exhibited at The Nobel Peace Center as a way of raising awareness to this effect, especially in terms of how our environment and our culture can influence food costs and the nutritional value of meals around the world.

Government Shutdown and It's Impact on Kids

This week's Federal Government shutdown has been an eye-opening experience for me as a public health student. First off, I didn't even know this was possible! I was too young to understand the implications the last time this occurred in 1995-96, but I am learning quickly that without a federal budget there is no public health.
 
Not only are the public health programs that I care about unable to benefit communities, but academics at the College of Public Health who are trying to conduct public health research are stuck - waiting on grants and websites to be updated. I read an article yesterday in the Washington Post which really made me think about the impact that this funding hold will have on the programs and populations I support:

1) WIC - The Department of Agriculture will stop supporting the Women, Infants and Children (WIC) program, which helps pregnant women and new moms buy healthy food and provides nutritional information and health care referrals to those who need it. According to a Forbes article, over 8.9 million low-income women and children are at risk for losing their access to stable food supplies.

2) Head Start - 1,600 Head Start programs around the country providing education, health, nutrition and other services to roughly 1 million low-income children and their families. They will slowly begin closing during a shutdown. This is on top of cutbacks that have already occurred this year.

3) Disability Benefits - Social Security administration won't have enough staff to schedule new hearings for those applying for disability benefits.

4) [Childhood] Cancer Research - As long as the government is shut down, the National Institutes of Health says it will turn away roughly 200 patients each week from its clinical research center.

5) Public Health across the board - The U.S. Department of Health and Human Services’ contingency staffing plan involves furloughing about half of its employees - which means bad news for key public health services. 

In my LEND traineeship, we always talk about that, as future leaders in healthcare, it is important to have our voice at the table when major decisions are being made. However, I am left frustrated by this outcome since the populations who are most affected had no voice. I understand that government officials speak for their constituents, but who spoke for the children that are now affected.

So where do we go from here? As I was writing my grant proposal for class and struggling to access the public data that I have taken for granted so many late nights, I came to the conclusion that we need to continue to move forward. I will continue to learn and help those in need, even if the government continues to stand still. I will continue to advocate for programs, research, and health reform because our country is on the precipice of change, and true leaders push on - even if they have to swim against the current.  

Dive Right In

I'm not sure where to begin, so I will start with something I know: gymnastics. Growing up as a gymnast, I learned to thrive on that feeling of uncertainty and fear just before throwing a big trick. That feeling of standing at the end of a four inch balance beam preparing to launch myself blindly backwards is familiar, and in a weird way, comforting to me. A year ago, I started graduate school with that same feeling in the pit of my stomach. Everything around me was new - new apartment, new roommate, new job, new significant other, new classes, building, professors, friends. I was anxious and nervous about what would lie ahead, but even more excited to dive in and learn about the broad world that is public health.

At that time, my exposure to public health was limited to a few interesting undergraduate courses and an internship with Ponseti International. As I listened to my classmates' experiences at orientation, I couldn't help but be a little jealous. Many had traveled the world, worked in communities, and helped vulnerable populations - real "boots on the ground" public health practice (although many of them may not have realized it at the time). I knew that each person I met had something unique to teach me, and I welcomed their stories and little lessons.

My fellow CBH students at the American Public Health Association Conference 2012

As I was thrown into life as a graduate student and started to lay the foundation for the rest of my education, I found myself constantly coming back to these five items as a kind of personal survival guide. I try to remember these five things as I move through my busy weeks:

1. Keep an open mind - public health is a constantly evolving field and draws upon many other disciplines. If you find yourself questioning how you normally would think about a problem or solution, then you are doing it right!

2. Engage and explore - Whether your in class or at a conference, turn off your phone, shut your computer, and open your mind. You will be amazed at how much you will get out of those moments without distractions. Don't worry, your 100s of e-mails will still be there when you're done.

3. Actively seek opportunity - There was so many opportunities out there that are waiting for you! Network, be enthusiastic, be willing to work for free, and learn as much as you can from each experience. 

4. Learn the lingo - Public health is stuffed full of acronyms and jargon - APHA, NACCHO, community based participatory research, sequestration. It's OK if you don't know everything right off the bat! My advice is keep a small notebook with you at all times and jot down things you don't know. Google them later.

5. Find your "me" time - Life as a graduate student is a balancing act (sorry for the cliche). My advice is find the time to do something just for yourself each week. For me it is an hour of yoga a couple times a week, and in the winter some Hot Cocoa and a book.

The purpose of this blog is to write freely about my experience as an MPH student - to share my passions, revelations, challenges and questions to the public health going on all around me. I hope to capture an organic viewpoint of what it is like to be exploring and navigating the field of public health as a student and growing professional. I also plan to bring in guest bloggers (colleagues and faculty) from my department to enrich my viewpoint and offer differing perspectives. This experience is one that is very new for me. I have never been one to journal or document my own interactions with the world, especially in a public venue. However, if gymnastics taught me one life lesson, it is that by making yourself a little uncomfortable every day, you end up with a product you can be proud of.

"Be brave enough to live creatively. You have to leave the city of your comfort and go into the wilderness of your intuition. You can only get there by hard work, by risking and by not quite knowing what you are doing. What you will discover will be wonderful: Yourself."
-Alan Alda