Tag Archives: Rishi Manchanda

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.


Here’s the Box, Now Stay Outside It


“Could a greater miracle take place than for us to look through each other’s eyes for an instant.” – Henry David Thoreau

Mr. Thoreau’s quote set the tone for a new campaign by the Cleveland Clinic in their Youtube video, “Empathy: The Human Connection to Patient Care.”  It was an eye-opening piece that has the ability to take you from the highest of human emotions to its very bottom depths.  Would you change the way you approach some interactions knowing what someone was going through or how they felt?

Earlier this week I was at home waiting for rental furniture to be delivered by a local company.  I was impressed that they were right on time, if not a few minutes early.  My next interaction is where it got touch-and-go.  I met one of the delivery guys out front and as he was walking with me to my door, he instantly said to me “the sleeper (couch) is not going to fit through the door.”  Of all people that would have known that, it was going to be him.  But this was no ordinary day.  And this was not the first hurdle that I have dealt with in order to get my place rented.  It was the final hurdle – the finish line was in reach – and here was this unsuspecting delivery guy who had no idea what he was walking into.  I was carrying so much frustration, resentment and anger all associated from being unable to secure a renter in over 45 days.  I initially approached one property management company to not only manage the property once I moved cities, but to also assist with marketing.  Everyone I spoke with drove home the message that “you’re advertising at the right time” and “peak season for renters are right around July.”  My ad was up and running right after July 4th and more than 30 people came through, but no applications were submitted.  I knew something was wrong and that the company I retained was not holding their end of the contract.  Plan G (at least it felt like we’ve come this far in terms of alternate solutions) was the decision to to rent furniture and consider short term rentals.  So needless to say, when this unsuspecting delivery guy instantly said that the couch wouldn’t fit without trying…I flew off my handle.  And this doesn’t really happen to me.  I’m a laid-back guy from California – I’m patient to a fault sometimes.  But this was no ordinary situation and after viewing that video from Cleveland Clinic, I’m curious if that situation could have been avoided, or at the very least, started off on a better note if we both knew where the other person was emotionally – if we could walk in each other’s shoes for just a minute.

I’m happy and relieved to report that I eventually calmed down and we actually had awesome conversations about football and the Washington Redskins situation and other fun topics about DC.  And the couch did fit.  Even if I had to smother that sucker with butter, it was coming through that door.

The day before the furniture was delivered, I attended a symposium hosted by DC Primary Care Association and DC Department of Health titled “Moving Upstream” mainly because I’m a huge public health geek and relish learning from other professionals.  The agenda was sent out two days prior to the event and I nearly fainted from excitement.  My idol (get over it, older people can have idols, too) Dr. Rishi Manchanda from the VA hospital system in Los Angeles was the keynote speaker.  I first saw him while I was a first year in graduate school and he gave a talk on praxis; something which continues to resonate with me to this day.  My perspective and “praxis” of my background and experiences is this blog.  And I am forever grateful to Dr. M for that.

Dr. M is a kind and giving man though, and he gave me a couple more presents that morning.  First, I had a chance to talk to him briefly before the day started and he gave me a couple pointers on a new project I’ve decided to undertake down in Durham, NC.  Next, during his keynote address, he told the story of one of his patients, Veronica, who bounced around the healthcare system for 3 years unable to resolve her chronic headaches.  Step-by-step, Dr. M described the process that he and his staff members took in his clinic.  Each patient would have a detailed intake of what brought them to the clinic – standard procedures for every healthcare setting nationwide.  The next set of questions, however, asked them about their living conditions, so by the time Dr. M came to see the patient, he knew a bit more of what to expect in their interaction.  After their consultation, he diagnosed her with chronic allergies and then referred her to two “specialists” on his staff.  One was a community health worker who would go with Veronica to her home to assess what may be detrimental to her health.  The next “specialist”, a public interest lawyer, would take the results of the assessment and ensure that Veronica was treated to proper living conditions as mandated by law.  Veronica came back a few months later and was feeling better.  Dr. M even described that he went to their desks and grabbed his two “specialists” and all three celebrated with Veronica on the spot.  A small win, but it reinforced the relationship and effort with all stakeholders.

I’m very optimistic about the future of medicine with stories like these and the leadership that both Cleveland Clinic, Dr. Manchanda and many others are leveraging to guide their work moving forward.  New technologies in tracking an individual’s data as well as improving access through telemedicine are new frontiers that will be a reality for more and more people.  My hope is that with this new technology, human connection and empathy will continue to be the foundation upon which all decisions are made.
“No one cares how much you know, until they know how much you care” ― Theodore Roosevelt