Tag Archives: upstreamist

Public Health in Action – Anchored Upstream

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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.

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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

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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.

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Public Health in Action – Rachel Safeek Fights the Status Quo with “Fight Stigma”

fightstigmaIn an earlier post, I marveled about Twitter and all the great things that have happened to me post-Twitter.  It blows my mind how much information there is out there on the internet…which is how I found Rachel Safeek.  Being the public health, upstreamist, social determinants of health geek that I am, I ran a Google search on “health disparities Duke” preparing for a trip down to Durham for one of my consulting projects.  Lo and behold, there were pages and pages of interesting websites, one of which was Rachel’s blog, blue devil banter.  Her perspective and activism was something that I wanted to bring into this blog.  What I value so much in activism and community mobilizing is that anyone and everyone has a voice – whether it’s a solo one or an army of voices – each and every one of us has a voice.

“Never be afraid to raise your voice for honesty and truth and compassion against injustice and lying and greed. If people all over the world…would do this, it would change the earth.” — William Faulkner

So without further ado…

Rachel Safeek
Founder, Fight Stigma Campaign
Duke University 2013
Program II: Health Policy, Human Rights, and Health Disparities

Me: How did you end up doing the work that you’re currently doing?  Student to activist to working at Duke.

RS: I first began working with HIV prevention and advocacy while studying global health as an undergraduate at Duke. I became interested in the various socio-economic factors that predispose women to HIV. My interests led me to spearhead a seven-month research project in Salvador, Brazil, investigating how violence (domestic, sexual, etc.) and economic vulnerability predispose women to HIV and other sexually transmitted infections.

Following my work with HIV, I joined and later became Director of an HIV testing program that offered free, rapid HIV testing at various locations in Durham, North Carolina, including Duke University Campus, Durham Technical and Community College, and El Centro Hispano, a resource center catering to predominantly Spanish speaking populations.

While engaging in HIV prevention work, I observed the manner and degree to which stigma was associated with HIV.  Moreover, overall sexual health served as a deterrent for many seeking HIV testing and/or medical treatment after sexual assaults, and openly discussing safer sex behaviors. This led me to found my organization, the “Fight Stigma Campaign” (FSC). The initiative was launched as a social media-based photo-campaign dedicated to educating the campus community about HIV/AIDS and encouraging HIV testing and open discourse surrounding safer sex, particularly among young adults.

After working with HIV prevention and advocacy for a year, I then turned my focus to HIV treatment. Currently, I am working as a Clinical Research Coordinator for the HIV drug trials at Duke Medicine, in which I oversee the enrollment and progress of patients in HIV drug studies at Duke. While I am now focused on the treatment end of HIV, I still dedicate significant time and effort to advocacy efforts for the FSC, all while I applying to medical school.  I hope to one day continue to work with issues related to women’s health and infectious disease as a medical doctor.

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

RS: As a Latina woman who represents diversity in healthcare, I am deeply motivated by a desire to give back to my community. Everyday, I have the privilege of engaging patients from a wide array of socio-economic and racial/ethnic backgrounds. These clinical experiences have afforded me the opportunity to observe first-hand the manner and degree to which racial/ethnic minorities are disproportionately affected by negative health status. Each individual interaction motivates me to continue along my trajectory of working with underserved communities—many of whom represent members of my own community—currently as a clinical research coordinator and HIV prevention worker, and later on, as a medical doctor.

Me: What do you think it will take for our healthcare system improve?  What do you think it will take our society’s health outcomes to improve?

RS: From a human rights standpoint, I believe that before health disparities can be adequately addressed, we must first acknowledge health as a human right. By ensuring individuals that they have a right to health, communities can mobilize to demand this right, raising awareness to the various socio-economic factors that prevent communities from attaining optimal health status. These socio-economic factors, including education level, access to healthcare facilities, transportation barriers, and poverty must be addressed in order to improve health care in our nation. I believe that these conditions stand a higher chance of being addressed if we can empower communities to vocalize their concerns by affording them the right to optimal health.

Me: In the health policy world, what do you think is the next big opportunity and how does this compare to the actual need of the population?  What I mean is that sometimes Congress and the needs of the public aren’t always on the same page…

RS: I think we can all agree that the Affordable Care Act represents a tremendous forward stride, in terms of affording individuals access to care. However, beyond health care coverage, there are still a multitude of factors that predispose populations to poor health, including lack of transportation to health care facilities, lack of access to sustainable nutrition, poverty, low socio-economic status, etc.

One prominent issue in healthcare that I believe is often overlooked is the lack of representation of minorities in healthcare settings. Having physicians and other healthcare workers of diverse backgrounds is necessary for appealing to the culturally-specific needs of patients.

According to the AAMC (Association of American Medical Colleges), African Americans, Hispanics, and Native Americans make up 25% of the U.S. population, but only account for 6% of doctors. Increasing the number of physicians from racial/ethnic minority backgrounds ensures the delivery of culturally competent and sensitive care, thereby fostering a sense of trust between patients and their providers and increasing patient safety and satisfaction. Minority physicians have also historically been linked to working with patients from underrepresented and marginalized groups, who often represent a large fraction of the sick population, further highlighting the importance of adopting progressive policies that encourage and aid minorities in their pursuit of careers in healthcare.

Me: What are the current needs in Durham, as they relate to social determinants of health (ie SES, poverty, access to care, transportation, safety, etc.)?

RS: Durham, North Carolina, home to Duke University, is uniquely nestled in the Research Triangle Park (RTP), which is renowned for having the highest concentration of MD’s and Ph.D.’s in the world. While boasting this impressive statistic, the city’s high yield of educated individuals also creates a gradient of educational disparities within the area. As a result, there are tremendous racial and socio-economic disparities between the faculty and students of Duke University and the rest of the city.

Duke University Medical Center, nationally ranked as one of the top 10 hospitals in America, plays an instrumental role in affording individuals in Durham County and surrounding counties and states top-notch care. Also, Duke University, as a whole, is the largest employer in the county. However, while the University affords Durham locals various job opportunities, I believe a disparity still exists. Like most of America, the large racial minority population does not comprise the majority of the decision makers who determine how resources are allocated. While there is some representation on boards, this is not enough. In the end, the decision-makers are the ones who control resource allocation, who drive change and make improvements to benefit the community, especially in healthcare.

I believe there should be more progressive policies that aid those of disadvantaged socio-economic backgrounds and under-represented minorities in their pursuit of higher degrees to help diminish the gap in racial/ethnic disparities in education and health.