Tag Archives: CDC

Public Health’s ‘Moonshot’ – Part 1

Advocates for cancer research and prevention efforts converged in Washington, D.C. last week for One Voice Against Cancer’s (OVAC) annual lobby day on Capitol Hill. OVAC, a collaboration of roughly 50 national non-profit organizations, delivered a unified message to Members of Congress on June 6 on the need for increased cancer-related appropriations. A point of discussion in my meetings with legislative staff was the President’s Budget Proposal for FY 2018, which featured budget cuts at both the National Institutes of Health (NIH) and Centers for Disease Control and Prevention (CDC) and increases for the Department of Defense. Armed with OVAC “asks”, I decided to focus my meetings with legislative staff from Senators Burr and Tillis and Representative Butterfield on the economic impact in North Carolina if funding levels were reduced. North Carolina is home to three National Cancer Institute (NCI)-designated cancer centers, which are awarded over $2B in annual NIH funding and employs thousands of employees.

Our advocacy training included a presentation by Dr. Warren Kibbe from NCI on the state of NIH funding and a quick brief on the Cancer Moonshot Initiative. Led by former Vice President Joe Biden, the initiative focused on concentrated and collective action to accelerate a decade’s worth of progress in preventing, diagnosing and treating cancer into a five-year time frame. The Cancer Moonshot has buy-in from academic, public and private sector partnerships. My immediate thought: why doesn’t public health have this type of dedicated initiative with annual federally-appropriated funds?

The Robert Wood Johnson Foundation’s Culture of Health initiative is public health’s “moonshot”. Its Action Framework parallels the Cancer Moonshot Initiative in identifying focus areas and key performance metrics to measure progress. RWJF’s Culture of Health has achieved significant buy-in from a myriad of cross-sector stakeholders. The only distinction between the two initiatives, from my perspective, is dedicated federal support. Imagine the possibilities if public health’s “moonshot” received the same attention and resources as the Cancer Moonshot Initiative. A decade’s worth of progress in a 5-year timeline for the social determinants of health would really change the trajectory of the field of public health.

In the next few posts, I plan to take a deeper dive on exploring innovative ways to address the social determinants of health, specifically at the local level, in the city where I currently live – Durham, North Carolina.

Below, I offer background on the U.S.’s healthcare system to provide a larger context the many layers and contributors to an individual’s health outcomes.

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Healthcare expenditures in the United States was approximately $3.2T, or $9,900 per capita, in 2015 which accounted for 17.8% of its gross domestic product (GDP). When compared to 12 other high-income member countries of the Organization for Economic Cooperation and Development (OECD), the U.S. spent significantly more annually. According to the Commonwealth Fund, the U.S. spent roughly $3000 more than Switzerland, the runner-up in per capita spending, in 2013. As a result, it outspent the next highest spender, France, by 5.5% of GDP in 2013. But despite its additional spending, the U.S. underperforms on population health outcomes such as life expectancy and chronic disease prevalence when compared with other OECD countries. Additionally in its analysis, the Commonwealth Fund compared healthcare expenditures to those spent on social services – retirement, disability benefits, employment programs and supportive housing, among others – for 11 OECD countries. In this comparison, the U.S. spent the least on social services at 9% of GDP, with Canada and Australia spending 10% and 11% of GDP, respectively. France and Sweden spent the most on social services at 21% of GDP. This imbalance in spending, posit the authors, may contribute to the country’s poor health outcomes.

Policies to improve population health have historically focused on the healthcare system according to Kaiser Family Foundation’s Heiman and Artiga. The Affordable Care Act, signed into law in 2010, expanded access to healthcare services for millions of Americans. However, as the authors explain, research demonstrates that healthcare is a relatively weak health determinant. Individual health behaviors, genetics and a broad range of social and environmental factors account for 90% of an individual’s risk for premature death. Thus, addressing the factors outside of the healthcare system may play a key role in improving population health outcomes, and the value it generates could justify reallocation of current spending levels.

Social determinants of health are “the structural determinants and conditions in which people are born, grow, live, work and age”. Examples of social determinants of health include social economic status, educational attainment, the physical environment, employment and social support networks. Social determinants form the basic foundation for each individual and his/her life experience. It also sets a baseline for future health outcomes. For example, an individual who is unemployed for an extended period of time may become homeless, food insecure and have limited access to healthcare services. It’s reasonable to conclude that this individual may be at higher risk of premature death due to his/her life experience. Unfortunately people all over the world have lives filled with adversity and struggle. Social, economic and/or environmental disadvantage creates differences in health outcomes, also known as health disparities, in populations across the world. One goal of Healthy People 2020, a strategic 10-year plan to improve U.S. population health, is to achieve the highest level of health for all people. Health equity includes the elimination of health and healthcare disparities.

One population of interest are known as “high utilizers” or vulnerable patients with complex social, behavioral and health needs. According to Anderson, the top 5% of individual utilizers account for about 50% of overall healthcare expenditures. Programs that pair patient navigators, community health workers and behavioral health resources with identified “high utilizers” have been implemented recently with hopes of improving health outcomes and generating value. A thorough review and analysis of the results for impact and effectiveness in improving health and cutting costs for this subset of patients is a critical next step.

Public Health in Action – Web Master and Lecturer Betty Jung

Mentoring

An Interview with Betty C. Jung, Web Master, Director of Public Health Expertise and Network Of Mentors (PHENOM) and Adjunct Lecturer, Southern Connecticut State University

Me: How did you end up doing the work that you’re currently doing? Describe the transition from graduation with a nursing degree to public health to academia to your website.  

Betty: When I graduated from NY’s Columbia University School of Nursing I worked as a staff nurse at New York’s Columbia-Presbyterian Hospital’s men’s urology department, where I was basically the medication nurse all the time, while conducting patient admissions, pre-operative teaching, patient discharge education and providing post-surgical nursing care. I was also in charge when the head nurse wasn’t there, which was 40% of the time. After my son was born, I worked part-time as a charge nurse in Babies Hospital, and then took some years off when my daughter was born. Then I worked as a school nurse, and when I was ready to return to the workforce I decided to return to school first to earn a graduate degree so I can teach health in high school.

While I was attending graduate school at Southern Connecticut State University (SCSU), the Master of Public Health program became available as a result of my letter writing to state legislators.  I switched to that program because I was interested in the scope of practice that Public Health offered. I did an internship at the Connecticut Health Department, and ended up being hired to work in the newly developed occupational surveillance program as the program coordinator for the adult lead surveillance program. From there I went on to work in family health, child welfare services, and chronic disease surveillance of cardiovascular disease and diabetes, all of which made the most of my nursing background.

I was hired by SCSU to be a thesis and special project advisor in their MPH program during a staffing shortage, and filled in teaching graduate Community Health Education, and undergraduate Introduction to Epidemiology. Eventually I began teaching undergraduate Wellness, and have been teaching this for many years. I love it.

I originally developed my Web site (which will be 15 years old on 8/25/14) to gain some practice in Web development because I was given the responsibility to work on web pages for the state health department’s Family Health Division’s intranet. Unfortunately there was no money to formally train me so I taught myself. Eventually I used the Web site to support the various activities I was involved with (e.g., support my teaching activities, provide a temporary site for a couple of organizations, and provide credible health information to the public). 

It is now the home of the Public Health Expertise Network of Mentors (PHENOM), a volunteer-based online public health mentoring program that currently comprise of 65 public health professionals working at all levels of public health (federal, state and local), in a variety of settings, from 18 different states, and 3 countries, etc. PHENOM is starting its 22nd year of mentoring services to the Internet community.  

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

Betty: That I am working on things, along with others, for the Public’s greater good. Public Health covers about every facet of Life, and there is always something that requires our attention. I use my Web site as a tool to communicate to the general public and professionals about issues that need to be addressed, and provide resources to address those issues. And, it’s always inspiring to know that there are many people working providing services (e.g., health, public health, social services, etc.) to those in need. I also enjoy getting feedback from visitors letting me know what they found helpful on the Web site

Me: What do you think it will take for our society to view health more seriously?  As in, why is health lower in priority to careers and education and relationships?

Betty: Good questions! Right now, Health is viewed in rather negative terms, I think, as in the cost of health insurance.  Anyone who can afford health insurance will tell you that it is costly, and what do they have to show for it? Those who cannot afford health insurance feel they are deprived of a basic right.  

Unfortunately, what we pay for in health insurance costs has little bearing on our health status or our perception of what being healthy really means. One can be fully insured and still be very sick because many of us fail to take care of ourselves in ways that promote health, or seek health care in a timely manner.  Then, there is the issue of a dysfunctional health care system.

Medicaid, the public health insurance program has been around for 45 years. While current studies show it to be somewhat effective, there are still gaps in services because of inadequate provider participation in Medicaid.

Also, we probably should distinguish what we mean when we talk about health care spending (e.g., insurance vs. delivery of services).  And, we really need to take better care of ourselves.

I think if we treat our bodies as if they were luxury cars, we would probably take better care ourselves. We would eat better so our bodies can run better, and while we need to buy car (health) insurance in case something bad happens, the longevity of the car would depend on good daily maintenance.  It is now possible to replace worn down parts, but consistent maintenance is key to keeping the car running.

It’s true that other factors, beyond us, also contribute to our health and well-being. These factors may require policy and environmental interventions to ensure that we can live in optimum conditions that support healthy living. This is where Public Health does its best work. But, when you look at the funding Public Health receives, internationally, it is minuscule as compared to what Health gets (basically health insurance, not necessarily health services).  I think that once Public Health receives appropriate funding to do what it has to do, for everyone, then society will start to view “Health” more seriously.

As for your second question, health careers are booming only because the Great Recession has eliminated many jobs in other economic sectors. Health service jobs are physically and mentally demanding work. Many of these are in the delivery of health services rather than in Public Health, which is too bad.

In the long run, it would be more cost-effective for Society to put more effort (and funding) into educating and enabling people to live healthy lives than to providing expensive services to those who are sick.   

Health actually should be a priority for everyone. Without our health we really can’t do all the things we want to do. But, even among those who work in the delivery of health services, many do not deal with stress too well and as a result become susceptible to cardiovascular disease, obesity and diabetes.  For example, 60% of nurses who work the night shift are obese/overweight! But, would you want to be admitted to a hospital that didn’t have 24/7 nursing services?

As for the last part of your final question, the CDC has recently reported that married men are more likely to have had a healthcare visit and/or to have had clinical preventive services in the past 12 months than cohabiting men.  Why would that be true? Because married women have earned the right to nag (my interpretation).

Me: Why are education and mentorship so important in general?  Where do you predict public health as a field to go in the next few years?

Betty: Life is a lot more complicated than it was just 50 years ago. Thanks to technology, how we live is changing a lot more rapidly than ever. Look at what electricity has done for society? Does anyone remember when we didn’t have a computer sitting in front of us – for everything? When you visit your health care provider, you will most likely be spending time with a computer as well.

Because of these rapid changes, it is more important than ever to have the education to help us navigate the ever-changing work environment. We all need skills that can be transferable and allow us to adapt as quickly as possible as the world changes around us.  This is where mentorship comes in to play.  Many concepts that we learn in school can be easily outdated within 5 years of graduation. So, it becomes vitally important to learn with and from those working in the field.
We all should adopt a mentor/mentee approach to our career development. Others can mentor us, while we mentor others. At any given time we can be in mentor/mentee relationships with a variety of different people. I think all institutions should formally support mentoring activities in the workplace to nurture their employees. It is shortsighted to think that developing employees would be a benefit to another employer, so it’s not worth spending money on professional development.  Workers who can grow professionally in their workplace tend to be happier employees and stay with employers that cultivate the professional growth of their employees, and happy employees don’t go looking for greener pastures.

As for predicting where public health would be in a few years? That is a hard question to answer. Right now, who would have thought the US would have to contend with a possible Ebola outbreak? One thing’s for sure, we will still have some kind of disease outbreak in the future because our environment is changing all the time. We hear about global warming all the time. What will the fallout be from that? We will still need to be prepared for disasters, as almost all natural weather events are beyond our control.

More than in any other field, Public Health has always rolled with the punches. It will continue to do so and will probably survive far better than any field that relies too much on specialization. Once again, think about computer technology. Anyone out there remember DOS? How many versions of Microsoft Office have people used in the past 10 years?

Specialized public health knowledge must be as fluid as the problems that keep cropping up. Public Health practitioners will have to learn to live with the fact that they must be what I call “serial specialists” during the length of their careers.  If we really take program evaluation seriously, and we should, then we have to expect the programs we work on to change, based on evaluation results. That’s the whole purpose of evaluation, to ensure the program is still addressing the issue.  And, if the issue changes, then the program must change. What ever happened to the National Tuberculosis Association? It became the American Lung Association.

In a way, this is really exciting for public health practitioners because they don’t have the luxury to be stagnating on the job.  And, if we view change positively, then professional growth is always a possibility.    

Me: What are the current needs in CT, as they relate to social determinants of health (i.e. SES, poverty, access to care, transportation, safety, etc.).  Social determinants of health are any factors that directly or indirectly affect health.  How does this compare with US as a whole and where are they similar?

Betty:  Ramon, I can only answer this in a general sense since I no longer work for the CT Department of Public Health…
Given that, like most states, the Connecticut state health department must rely on external funding sources to carry out its mission. Funding is never as comprehensive in terms of amounts or funding, so we make the most of whatever funding the department would get.  To address issues associated with the social determinants of health, it is necessary that the state health department collaborate with other state agencies that would address issues associated with low income populations, etc.  After all, state health departments must spend all their resources on primarily protecting the public’s health and ensuring that basic preventive services are available so that disease will not spread. This is just the tip of the iceberg of what state health departments must do.

To address social determinants of health, Connecticut’s Department of Aging has a renters rebate program, the Department of Consumer Protection regulates home food service, the Department Development Services provide autism services, and services for those with special needs, etc.  

As to how Connecticut is faring, one could check the Agency for Healthcare Research and Quality (AHRQ)’s Web site’s National Healthcare Quality Reports

Comparatively speaking. Connecticut is doing better than the country as a whole, across 124 quality measures.  The US has achieved 34 of the benchmarks, vs. Connecticut’s 48. In looking at measures by race and ethnicity, the US is far away from benchmarks for Blacks in 34 measures, 26 benchmarks for Hispanics, 21 benchmarks for Whites, and 14 benchmarks for Asian/Pacific Islanders.

Connecticut, in comparison, was far away from the benchmarks for the White, Black and Hispanic communities in the areas of long-stay nursing home resident health issues, adult home health patients who had hospital admissions and urgent, unplanned medical care. For its Asian Pacific Islander community, short-stay nursing home residents with pressure sores and moderate to severe pain were far away from the benchmarks.

So, there are online statistical sources available to look at quality measures, for all states, that are useful for evaluating how well any geographic entity is doing in addressing social determinants of health by how well they achieve national benchmarks and quality measures.

Me: Thank you Betty for bringing all your experiences, knowledge and wisdom to this blog and sharing your thought-provoking insights to the greater public.  At the end of the day, it’s about helping each other out so that we can all improve our respective lives.

“No one is useless in this world who lightens the burdens of another.” ― Charles Dickens