Tag Archives: Affordable Care Act

Public Health in Action – Anchored Upstream


Public Health River Metaphor

A man was fishing in the river when he noticed someone was drowning. He pulled them out and attempted to resuscitate them. Shortly afterwards, he noticed another person in the river and saved them too. He then noticed another, and another and another. Soon he was exhausted and realized he would not be able save all of the drowning people.

He went further upstream to find out why all these people were falling into the river.

On arriving further upstream, he discovered a broken bridge was causing people to fall into the river and end up drowning where he had been fishing.  He decided he would fix the bridge to stop them falling in, instead of fishing them out after they were already drowning.


There’s a radio ad campaign for the Powerball Lottery in my local area, Raleigh-Durham, North Carolina that has stood out to me more than the hundreds of others I hear on the radio. In the ad,’Wolfman’ (picture Michael J. Fox in the Teen Wolf movie) visits the barber shop for his regular hair cut. ‘Wolfman’ throws out a few ideas – maybe I should shave it all off? “Or maybe a mullet?” His barber asks why the sudden change from his usual cut. ‘Wolfman’ described that his life was so monotonous lately and he wanted to change things up a bit. The barber then responds by recommending that ‘Wolfman’ purchase a Powerball ticket because every jackpot is worth at least $40 million – a life-changing amount; a change that  coincidentally ‘Wolfman’ was looking for. A disclaimer followed in the final seconds stating the odds of winning a Powerball jackpot, which was a measly 1/292 million. Ads, like this one, that tap into our well of emotions leave us particularly susceptible to any product that marketers are hawking, despite the impossible odds or practical necessity in one’s life.

While 1/292 million are nearly impossible odds, 1/4 seems almost certain in comparison. A recent article from the Atlantic highlighted results from Urban Institute’s study on medical debt. 23.8% of adults under 65 in the US has medical debt. Southern states, like Mississippi and Arkansas, have higher rates of medical debt – both over 35%. Furthermore, insurance coverage had a minimal positive effect: 23% of adults with health insurance still had medical debt compared to 31% of uninsured. As mentioned in the article, this has been a common criticism of the Affordable Care Act, aka Obamacare: that expanding health insurance does little to reduce high costs of health care for individuals (out-of-pocket costs) as well as the healthcare system as a whole.

Health policy in most recent years have been focused primarily on health insurance and affordable access to healthcare services. In the river metaphor above, focusing on health insurance would be akin to pulling people out of the river while they were drowning – providing them healthcare when they were sick, rather than figuring out how to prevent, or at least greatly reduce the risk of, illness. In public health and health care lingo this is what’s referred to as “looking upstream.”

In my interview below, Dr. James Leone, professor at Bridgewater State University, describes his career in “looking upstream.” Other upstream heroes of mine include:

Dr. Rishi Manchanda

Dr. Camara Jones


Me: How did you end up doing the work that you’re currently doing?  Describe your journey to your current role as professor at Bridgewater State University.  Describe why you’re passionate about Improving men’s health…why others should care about the health disparities between genders.

James Leone: My journey into public health education and higher education was a bit random/arbitrary. I began in clinical practice serving as a certified athletic trainer (ATC) where I worked in various settings including: professional with the New England Patriots, clinical outreach at high school, collegiate and physical therapy clinics. I also worked with coordinating rehabilitation clinics and strength and conditioning services in a variety of settings. Not too long into my clinical practice, I received an offer to teach sports medicine/athletic training at Southern Illinois University Carbondale, which was a new challenge for me professionally. I continued to teach and clinically practice, but my love of education rose to the top of my priorities, so I pursued a PhD in public health education. I saw value in what I could contribute on an individual level with people, however, my brain has always been geared towards the “bigger picture” – I guess you can say I embrace an upstream mentality/approach. This was my entry into health promotion and public health studies. I made my way up to Bridgewater State University (BSU) after serving on faculty at Southern Illinois University Carbondale, Northeastern University, and The George Washington University (GWU). Additionally, I currently serve as an adjunct professor at Northeastern University where I have taught courses in athletic training, physical therapy, physician assistant studies, and recently in the master of public health program.

As previously mentioned I have embraced a more “upstreamist” approach in my world and professional view. That said, I realized that male health always seemed to be lacking whether from personal experience or reviewing study after study and large data sets. I always have championed efforts to advocate for groups, be it my athletes or gender (in this case). Also, in 2007 I was approached by my former Chairperson at GWU to offer a class in men’s health, which I quickly embraced since my thought process was already in-tune with this topic. I quickly realized that evidence was lacking in terms of “why” men live sicker and die sooner than women. Also, there were few academic resources (i.e. books) from which to facilitate the topic. I set out consuming as much as I could to develop my course and my knowledge in this area of research. This journey led me to propose a textbook on male health (published in 2012) as well as develop two courses on male health (one at GWU and the other at BSU, presently). I am currently pursuing opportunities to develop male health curricula further so that beyond greater awareness of the topic and issues, we can move dialogue into action and advocacy by training public health professionals and providers on gender-specific needs of men and boys.

So, why do I care about male health topics? I have always been an advocate for people, ethics, and basic human rights. Poor health outcomes in males challenges these aforementioned principles, negatively impacting overall population health. From the public health perspective, we are morally and professionally obligated to help right these wrongs so as to create a more equitable society aimed at a “true public health for all.” I believe Sir Geoffrey Vickers captured it best in his quote, “public health consists of “a successive re-defining of the unacceptable.” I believe gender disparities, particularly those affecting men have been “unacceptable” and warrant our full and undivided attention at present times.

Me: What inspires you on a daily basis, especially when things get hard?

JL: My commitment is based on my ethics and morals, which guide my actions. My intolerance for average often guides my “drive” to improve most things in my personal life and professional practice. Knowing that I do work that directly corresponds to people’s health and experiences is more than enriching for me on a daily basis. When times get rough I often remain mindful of the transient nature of life and experiences – the viewpoint “nothing is guaranteed in life” often helps me to keep my life and work perspectives in check most days.

Me: I saw your presentation at this year’s American Public Health Association (APHA) conference on men’s health as a national security concern.  Can you describe your perspective on this issue?

JL: I was in a graduate school lecture discussing public health initiatives and Harry Truman’s 1946 speech was referenced in the talk. As part of that talk, Truman commented on the nature of the military and investing in the health of the youth to strengthen the defense system of the U.S. Of course, at the time, the vast majority of the military were younger men whose overall health and qualifications for military service were being called into question. The latter point got me thinking as to what it would be today; likely, things have gotten worse with rising overweight and obesity issues nationally. This perspective motivated my presentation at APHA in November. Overall, I think this is an incredibly important issue for two main reasons: 1. Of course we want to a strong system of defense if called upon, and 2. And perhaps most importantly, poor men’s health brings to light the overall issues in male health in the U.S. When we are able to gain the attention of the Department of Justice and Department of Defense, we might actually see Congress move on some of the issues in men’s health that we have been advocating for over the past few decades.

Me: What made you decide to be involved in the men’s health movement and the American Public Health Association Men’s Health Caucus (MHC)?

JL: I saw the APHA MHC as a strong platform from which to pool my energies and resources on advancing male health. I value like-minded people, but also, I am challenged by various ways of thinking and working towards solutions in these groups. I have learned that even though there is a shared value and perspective, we all have something unique to contribute to the conversation over men’s health. The men’s health movement attracts me simply because we as a society must look upstream to the issues that we generalize and deal with downstream. We have grown too normalized with poor men’s health and the forces that drive it. I think working with Men’s Health Network, MHC, and APHA can embolden an area that has gone largely unnoticed even at the detriment of society.

Me: What are the current needs in the Boston metro area (or focus in on the city you live in) as they relate to social determinants of health (i.e SES, poverty, access to care, transportation, safety, etc.)?

JL: I consider Boston and the surrounding areas as “lucky” because we have so much access to health, healthcare, education, and most of the social determinants that can positively affect population health. However, when we look below the generalized population data, we still see a consistent and stark contrast in the health of the privileged and the socially marginalized as with most other major cities. Boston struggles to meet the needs of harder to reach populations and men just like most other major cities in the U.S. We do have some excellent and progressive programming such as the Men’s Health Center (Whittier Street) in Roxbury and the men’s health program through Cambridge, however, the salient question is always: are we meeting the needs of the most vulnerable at the right moments so as to promote long-term individual and population health – I guess time and statistics will tell that story.


Why Artificial Intelligence Excites Me, Then Worries Me

patchAugust 27

Twitter is something else.  I signed up to Twitter a few years back, but never really did anything with it – mainly because I didn’t really understand how to leverage it to the fullest.  Fast forward to roughly a month ago and I’m a tweeting – bordering addicted – fiend.  If (the optimist in me says when) you check out my Twitter page (@randomRPL) you’ll notice that I tweet a lot.  Like all the time.  And it’s not a bot or HootSuite managing my social media.  This is me when I have a few minutes of free time.  I’m fortunate enough to live in a city with a solid public transit system, so that’s where I spend quality time on the Twitterverse.  But don’t worry, this is borderline addiction is moderated by my regular yoga practice at my local yoga studio.  Yes, I practice yoga.  Yes, it gives me some zen.  And yes, my addiction to social media is on the healthy side – there’s a method to my Twitter madness.  So, don’t panic…yet…I’ll let you know when to panic when I literally type “PANIC” below.

Featured in this morning’s Washington Post: Express this morning was a piece titled, “Look, D.C., no hands!”  Yes, the driverless car made it to the streets of DC for a test run.  I can only imagine how entertaining it must have been to witness the experiment in person.  How exciting is it that we are finally at the point where the science-fiction futuristic movies are finally turning into reality?  Remember TimeCop back in the 90s?  I know someone else saw that movie, so save the eye rolling for policy debates and all the inaction happening in Congress.

Here’s where my excitement stalls.  The authors describe that computers can detect certain things that happen – in this case a police officer managing the flow of traffic – but it cannot (at least at this point) detect the context of any situation – at least not as of this round of testing.  If you have ever driven in Washington, you know how completely nuts it is out there.  If you have not driven in Washington, please save yourself the road rage and stress and stay on public transit, taxi, Uber, Capital BikeShare or just walk it out.

I have complete faith and trust that Artificial Intelligence (AI) technology will continue to progress towards the sophistication and understanding that human beings possess.  I am excited to see the next generation of technology.  Heck, I would probably ride in a driverless car in the near future if given the opportunity.  But on two conditions: 1) the AI technology has to be sophisticated enough to understand and react to contextual factors (e.g. road rage) and 2) it would have to be in a less dense setting.  Innovation has come so far and we have that much further to go…

Which brings us into my favorite topic: healthcare.  How can we innovate in this field to deliver our patients – friends, family members and ourselves – quality health care that leverages technology to automate a variety of time-intensive, laborious things?  Twitter is one example of innovative, disruptive technology.  It not only delivers consumable pieces of information in real-time, but its technology also recommends connecting with other individuals based on similar interests.  Maneesh Juneja and I were matched via this Twitter algorithm and I could not be more grateful to the Twitterverse for this.  Maneesh is a digital health guru and is well-versed in future technologies to improve health.  He is constantly tweeting and in a sense, teaching a virtual class on health innovation.  I feel privileged enough to be in the front row and enjoy reading many of the articles he links to from his handle @maneeshjuneja.  Another teacher of mine in the Twitterverse is Dr. Kevin Pho of KevinMD.  Dr. Pho curates the most relevant articles in the field and tweets them to his 100,000+ followers.  The topic of robots in healthcare triggered in my mind when reading the driverless car article.  There are a few articles on the site that are worth reviewing: Robot Caregivers; How Robots Will Teach Us Who We Are As Humans; and Will Robots Reduce the Need for Doctors?  All three feed into a dialogue that we should be having on a larger scale.  Are certain technologies capable of easing the burden on healthcare professionals in a way that it does not jeopardize health outcomes?

Let’s circle back to the points I brought up about AI and context.  Imagine a robot with its sophisticated computer systems having to understand the contextual nuances as it relates to a healthcare setting.  Healthcare providers are already facing overwhelming demands when it comes to delivering quality healthcare to their patients all while balancing the needs of the business side of things – reimbursement claims, proper and secure patient records and malpractice, among other pressing issues.  The million dollar question is how can we integrate appropriate AI technology to ease the burden on health care providers?

As I stated earlier, in order to have me ride in a driverless car, the situation would need to address my aforementioned conditions.  In the healthcare world, I cannot even imagine how many more conditions are necessary before I could trust my own health and well-being in the hands of a robot, regardless of how sophisticated their AI technology might be.

Now is the time to PANIC.  I throw that word out there not to panic for the technology itself, but because the discussions we are having on healthcare at this point are simply useless.  The most talked about topic in healthcare is on reforming, repealing or strengthening the Affordable Care Act.  I completely understand that this is an important piece of legislation that needs to be handled appropriately and I also understand that it is not perfect.  But all the divisive rhetoric being slung from both sides are not productive.  The worries flowing from my mind have to do with the lack of focus, vision and discussion on innovative solutions to move our country, collectively, forward.

Let’s not forget that health knows no party line.  And neither does compassion.

“Lead me, follow me, or get out of my way.” — General George Patton

Engaged in Thought

cenrAugust 23

I was fortunate enough to attend the “Engaging Patients, Families and Communities in all Phases of Translational Research to Improve Health” Conference this past Thursday and Friday because it stimulated some serious thought and discussion amongst attendees, but most importantly myself.  Conferences are usually worthwhile because attendees are typically doing similar work.  An added feature is the sharing of ideas, best practices and stories – the dreaded “networking” – can actually be broken down into genuine conversations about helping each other perform their respective careers better.  Most conferences meet this basic expectation.  But this one was different.  It went above and beyond my expectations for several reasons, which I will describe below.

First, the size of this conference was extremely manageable.  Roughly 200 attendees registered to attend and all but a dozen or so made it to Bethesda to hear keynote speaker Dr. Chris Austin kick off Thursday with laughter and thought-provoking questions.  Out of the 180+ that attended, I can safely and confidently say that I was able to engage with 20 of them in meaningful conversation regarding potential opportunities to collaborate in the near future.  Contrast that with a larger conference, say APHA’s annual conference of a massive 30,000+ attendees, and it’s no wonder why attendees stay within their subsections and specialties.  This conference provided me with ample opportunities to engage with and learn from professionals doing completely different work.  And that to me was particularly valuable.

I touched on it earlier, but I was very impressed with the wide range of experts in the field of public health and community-based research.  One group showcased their work to improve health outcomes in Amish communities and another described relaying crucial health communication messages via text messages in rural health clinics at various sites in Kenya.  Talk about learning opportunities!  And this is my favorite way to learn – seeing problems being solved in the field as they relate to the realities of life and then interacting with the investigators to learn how these interventions could be replicated to improve health in other populations.

Lastly, the agenda was designed to introduce ideas via speaker presentations then move into smaller breakout groups to tackle more specific questions.  One specific breakout session that I attended dealt with the ethical implications of community-based research.  Here were a few questions that were left in my mind to sort out post-conference as I continue working at the community level:

*As researchers, what value can we provide back to communities in exchange for critical research data?  

*How can we make the relationship more mutually beneficial?

*What if the research results did not shed the community in a particularly positive way – think of the negative implications that could arise if the media reported on those same results

*The idea of research and the value of official academic research compared to “findings” or “observations” seen in communities…is one necessarily better than the other?

For the reasons aforementioned, I personally thought this conference was very valuable to my work as a public health professional.  But, similarly, it also leads me to think that much more work needs to be done outside of our own “public health bubble.”  Dr. Austin of the National Center for Advancing Translational Sciences at the National Institutes of Health illustrated this with a simple, yet extremely profound anecdote.  He described meeting with members of Congress recently and one of the members asked him about his work in linguistics.  Apparently that member read translational sciences in the title of his division and assumed it was translating language rather than public health science.  Viewing this from a public health lens, I would shake my head and laugh.  But viewing this outside our “public health bubble,” I probably would have said the same thing or asked, what does this really mean?  Even in my own experiences when trying to explain what public health is to people from all walks of life, to put it simply, it is a complex conversation to have.  Which is why I strongly believe that we as public health professionals need to do a better job at relating to and forgiving others for not understanding ideas and concepts from our perspective.  One example of this is public health funding.  Public health funding was increased under the support of President Obama and written into the Affordable Care Act back in 2010.  Shortly thereafter, resulting from the many tumultuous battles to reduce federal debt and annual federal budgets, public health funding was the first on the chopping block.  Many members chose to redistribute funds previously appropriated for public health work to budgets of the Department of Health and Human Services.  The same funds which were originally set aside to boost prevention efforts in communities nationwide.  This left public health professionals – including myself – outraged.  Why can’t the appropriations for the Department of Defense be on the chopping block instead?

But now it all makes sense.  The dots are finally connecting because of that anecdote Dr. Austin shared.  One of the main reasons that the field public health has trouble getting traction with funding streams is that the greater public – whose health we ironically serve to improve – doesn’t really know what we do.  And when a member of Congress sees a significant budget devoted to what appeared to them as “translating language,” then our efforts will always be reactive in nature – why are you taking from our much needed annual appropriation?  Therefore we must strive to espouse one of the basic principles of public health: take action for a proactive solution to funding – “Dear members of Congress, this is why we need what we are asking for.”

Until we get to that point, we’re still downstream on that river asking why there are so many people falling in.

I know we can do better and I am confident that we will.

“Anybody can become angry – that is easy, but to be angry with the right person and to the right degree and at the right time and for the right purpose, and in the right way – that is not within everybody’s power and is not easy.” — Aristotle