Wednesday, November 30, 2016

Are you biased?

Maria Mora-Pinzon, MD, MS
Preventive Medicine Resident
School of Medicine and Public Health
University of Wisconsin - Madison
Twitter: @mariacmorap

Look at this picture:
DF-12054 – Kate Mara as Sue Storm and Michael B. Jordan as Johnny Storm face off against an incredibly powerful enemy. Photo Credit: Ben Rothstein - From:

What is the relationship between those two characters??
Are they friends?  Are they teammates? Are they family? Are they a couple?

If you know the movie - or the original source - you know that they are siblings. For some reason the only explanation for different skin color was that one of them was adopted, because siblings can’t be of different skin color, right?

Newsflash…. Yes, they can!, as seen in google or my own family picture

Now think about this: 
A father and his son are in a car accident. The father dies at the scene and the son is rushed to the hospital. At the hospital the surgeon looks at the boy and says "I can't operate on this boy, he is my son." How can this be?

If you thought "This is an identification issue, maybe an Uncle? Step-father? God-Father?" before you said "The surgeon is the mother" then you might be biased about how a physician looks like. (You can find many examples of situations where these biases were used: #IlookLikeASurgeon #WhatADoctorLooksLike)

The point is, that
we are all biased (it is OK, it happens, don’t feel guilty about it) and you can take a test (The Implicit Association Test (IAT)) to identify your biases (Race, gender, sexual orientation, weight, religion, and many more). You can read some research regarding this test here.

Bias occurs in everyone (Physicians too, e.g.
here, and here). Although we are not sure WHY it happens, some experts believe it is related to our tendency to categorize, and that some associations (e.g. latino=lazy, black=bad, women=nurturing, women=homemaker) might be a result of our experiences, and media exposures (e.g. here, here, and here). What we know is that bias can affect behavior, so it is important to recognize them and make sure we don’t act based on those biases.

I am biased. What should I do now?

From the Project Implicit website:
“It is well-established that implicit preferences can affect behavior. But, there is not yet enough research to say for sure that implicit biases can be reduced, let alone eliminated. Therefore, we encourage people not to focus on strategies for reducing bias, but to focus instead on strategies that deny implicit biases the chance to operate. One such strategy is ensuring that implicit biases don’t leak out in the first place. To do that, you can “blind” yourself from learning a person’s gender, race, etc. when you’re making a decision about them (e.g., having their name removed from the top of a resume). If you only evaluate a person on the things that matter for a decision, then you can’t be swayed by demographic factors. Another strategy is to try to compensate for your implicit preferences. For example, if you have an implicit preference for young people you can try to be friendlier toward elderly people. Although it has not been well-studied, based on what we know about how biases form we also recommend that people consider what gets into their minds in the first place. This might mean avoiding television programs and movies that portray women and minority group members in negative or stereotypical ways”.

My personal take: Keep an open mind, what could be logical/normal for you might not be so normal for others and vice versa, avoid assumptions until you know the full story, and don’t act on your biases!

This blog was inspired by my attendance to a meeting titled Unlearning Racism hosted by YWCA Southeast Wisconsin, which was part of the monthly meetings of the Wisconsin Population Health Service Fellowship. At this meeting, we learned about the history of systemic racism and how biases affect behavior and lead to disparities in health and health care. If you would like to read about these topics check the following resources:

Wednesday, October 26, 2016

Health and Racial Equity at the City of Milwaukee Health Department from a Current Fellow, Former Fellow, and a Friend of the Fellowship

Salma Abadin, MPH
Wisconsin Population Health Service Fellow – 2nd year
Violence Prevention Research Coordinator - Milwaukee Homicide Review Commission, Office of Violence Prevention
City of Milwaukee Health Department
Milwaukee, WI

Anneke Mohr, MPH, MSW
Wisconsin Population Health Service Fellow 2011-2013
Health Project Assistant – Fetal Infant Mortality Review
City of Milwaukee Health Department
Milwaukee, WI

Marques Hogans, MPH
Friend of the Fellowship
Public Health Educator – Men’s Health Program
City of Milwaukee Health Department
Milwaukee, WI

How does the most racially diverse city in Wisconsin address racism and economic inequality to promote health equity? Recent events across the country have put the topic of race and equity at the forefront of national conversations.  Implicit bias is now a catch phrase of presidential debates and public radio.  For those of us working in Milwaukee, we are in the position of witnessing inequities first hand while struggling to get institutional buy in and a coordinated approach to address health and racial equity.  As public health professionals we recognize how important and necessary it is to integrate and operationalize health equity principles in our work. While there is some really amazing work happening nationally, regionally, and locally, we feel that there are opportunities for us to recalibrate and be intentional about aligning our work using an equity lens.

Earlier this year, we started having conversations around how we can bring more of a health equity lens to the City of Milwaukee Health Department (MHD).  We see the need in our work – violence prevention, maternal and child health, and men’s health – to address root causes of health outcomes.  African American women in Milwaukee experience pregnancy and infant loss at a rate three times higher than white women.  Changing individual behaviors will not reduce this disparity unless we also reduce poverty, discrimination, and the chronic stress that increases the risk for prematurity, the leading cause of infant mortality in Milwaukee.  The case is similar for violence across the City. Data from 2015 indicate that homicides and non-fatal shootings occurred about 4.5 times more frequently in lower socioeconomic status (SES) ZIP codes compared to middle and higher SES ZIP codes. Even further, black males ages 15-24 are victimized at a shooting rate of 1109 per 100,000 city inhabitants compared to white males at 9 per 100,000. For homicides, the victimization rate for black males is 187 per 100,000 per city inhabitants compared to 4 per 100,000. 

We’ve been able to learn from many in the fellowship community, including both current and former fellows and preceptors, who have been able to share their resources and ideas. In particular, Carly Hood and Evelyn Cruz shared their trainings and presentations they developed at the Wisconsin Department of Health Services-Division of Public Health to educate staff on health equity using NACCHO’s Roots of Health Inequity curriculum. Geof Swain has shared his expertise and work around the social determinants of health and health equity, specifically the 7 Foundational Practices for Health Equity, which are built on the WHO’s Conceptual Framework for Social Determinants of Health. Geof has used the image below to show how the foundational practices could be mapped on the Triple Aim of Health Equity, three objectives developed by the Minnesota Department of Health to advance health equity. 

We’ve traveled to conferences, including the Government Alliance for Racial Equity’s Midwest Convening on Racial Equity and NACCHO, to learn from other health departments across the country as well. We took the opportunity to have a conference call with Jordan Bingham, the Health Equity coordinator at Public Health Madison Dane County to discuss what she has been able to accomplish in Madison as well as challenges she has endured. We’ve even tapped into local resources at the YWCA and met with the Racial Justice Director who facilitates the Unlearning Racism course in the Milwaukee area.

In all this gathering of information and learning, we’ve now asked the question “what do we do with it all?” We want to be purposeful in planning how our efforts fit into a mechanism that is sustainable but also want to hit the ground running with some of our ideas. In discussing our efforts to bring dialogue and strategies around health equity at MHD, we’ve been able to find other champions in the department who are supporting the effort, including Fiona Weeks, Erica LeCounte, Geof Swain, Angie Hagy, and Michael Stevenson. We are meeting in the next couple weeks to draft language around how we define health equity, health disparities and social determinants of health; identify current examples of work at MHD that already operates from an equity perspective; and brainstorm what MHD’s health equity framework or roadmap could look like.  As something to start in the short-term, we are collecting names of all MHD employees who have taken the YWCA’s Unlearning Racism course to start an alumni group that would meet regularly to discuss topics related to health, social and economic justice.

We know this work takes a lot of creative and dedicated minds, and want to extend the offer to anyone in the fellowship community (or reading this blog) who may be interested in getting involve to get involved! Please share your ideas, concerns, resources, and/or lessons learned with us!

Monday, May 23, 2016

What did we learn from those conferences? – Leslie and Salma report back.

Salma Abadin, MPH
Wisconsin Population Health Service Fellow – 1st year
City of Milwaukee Health Department
Data You Can Use
Milwaukee, WI

Leslie Tou, MPH
Wisconsin Population Health Service Fellow – 1st year
Lifecourse Initiative for Healthy Families
MCH Program at the Department for Health Services
Madison, WI

Hi fellowship community! As you can see, we had to get a little creative with our interview since we work in different cities. We both attended conferences in April and wanted to highlight our experiences. We came up with seven questions to share some of our learnings and how attending the conference has impacted our work. Please feel free to contact us if you have any questions or want more information on either conference!

Salma’s report:

What conference did you attend?
I attended the Midwest Convening on Racial Equity in Chicago, IL on April 25, 2016. It was hosted by the Government Alliance on Race & Equity (GARE), which is a national network of government working to achieve racial equity and advance opportunity for all.

How will the information presented at the conference help your work?
For me, sometimes health equity seems unattainable, but attending this conference really helped me see the possibilities of success around health equity. People across the country are invested in working with each other to advance equity and enhance success for all. GARE provided their published Racial Equity toolkit as a way to operationalize equity. It includes a worksheet that can be used at multiple levels. The overall questions are:

1. What is your proposal and the desired results and outcomes?

2. What’s the data? What does the data tell us?

3. How have communities been engaged? Are there opportunities to expand engagement?

4. What are your strategies for advancing racial equity?

5. What is your plan for implementation?

6. How will you ensure accountability, communicate, and evaluate results?

They also provided examples from Seattle, WA and our very own Madison, WI, two cities that have used the tool. The City of Seattle passed an ordinance in 2009 that required all City departments to use the toolkit, in particular for all budget proposals. In 2015, the mayor of Seattle required departments to use the toolkit at least 4 times every year, and hopes to include aspects of the tool in performance measures. Applications of the Racial Equity Tool in Madison included adopting a new mission, vision, work plan, and evaluation plan with a racial equity lens in the Clerk’s office and incorporating staff and stakeholder input, racial equity priorities and to guide goals and objectives for strategic planning at Public Health Madison & Dane County. The toolkit has been a great way to start having conversations with my colleagues in Milwaukee about what we can do to use a health equity lens in our work.

What were other attendees’ backgrounds? Any tips on networking?
One of the goals of the conference was to "further cross-jurisdictional, cross-community, and cross-sector strategies for racial equity with partners in housing, criminal justice, employment, education, transportation, public health, immigrant groups, and environmental justice." Attendees worked in many of these arenas through communities, businesses, nonprofits, and government. The workshops were small (no more than 25 people) and interactive, so there was plenty of time to network and introduce yourself. I also knew a couple of people at the conference and that helped in being introduced to their colleagues and people in their networks.

What were some of your favorite sessions/posters/presentations?
My favorite panel discussion was entitled "Eliminating Institutional Racism in Criminal Justice." The conversation focused on how policing and the role of police leadership are changing. Paul Schnell, Maplewood, MN police chief, emphasized that police officers’ role is to create and build a stronger community, which he sees as a fundamental difference in the culture of policing. The measure of success is not the number of incarcerated individuals, but rather if he and his colleagues serve and support communities to be stronger and safer. One other interesting comment was that the idea of power around safety and policing is being redefined. Power needs to be given up and redistributed, and police authority is ultimately given by the communities they serve.

Was it everything you were expecting or did you hope to get something else out of the experience?
To be honest, I did not know what to expect. What I appreciated was the focus on shared learning and finding new partners and frameworks to help support or improve your work. Presenters and organizers of the conference offered tools and strategies to take back home and use in our own work. I’m excited to see what the follow-up from the April conference will be like because I left wishing the conference was longer than a day.

Any other takeaways?
There are an incredible number of people dedicated to achieving health equity work and they are willing to help each other. Several people attended from Milwaukee and we are planning to reconnect in the coming weeks to debrief on the conference and brainstorm ways to collaborate with an equity focus. It’s energizing to know that many people in Milwaukee are ready to work together and make health equity a reality.

What’s the next conference you want to attend?
I’ll be attending the NACCHO conference in July in Phoenix, and the theme is "Cultivating a Culture of Health Equity." I’m interested to see what the similarities and differences are from the Chicago meeting to the larger, national conference. Stay tuned J .

Leslie’s report:

What conference did you attend?
I attended the Association of Maternal & Child Health Programs (AMCHP) 2016 Annual Conference in Washington DC in April this year.

How will the information presented at the conference help your work?
I’m new to MCH work at the state level and I thought this conference was a unique opportunity to hear about up-and-coming- innovative strategies from different programs across the country, as well as hear from the federal level on updates and current policies around Title V funding. Title V is critical as it is the only federal program that focuses on mothers and children. You can find more information here.

In my fellowship, I am dual placement: I split my time between the Lifecourse Initiative for Healthy Families (LIHF) and the MCH Program at the Department for Health Services. I love how overlapping the positions are- there is a shared vision of health equity among all mothers and children in Wisconsin at the heart of both placements but there are obvious differences in state public health work versus university initiative work. I loved that the conference covered both these perspectives- state, governmental work as well as the community grassroots approach and the challenges, limitations and advantages that come with each. I really appreciated going to different presentations and workshops and having great takeaways for both placements. 

What were other attendees' backgrounds and professions?
AMCHP is a large, national conference that is predominantly attended by state health departments, research institutions and other organizations working to "to improve the health of women, children, youth and families, including those with special health care needs".

State Maternal and Child Health Programs (MCH) are well-represented at this conference as there is a huge focus on Title V programs. This conference serves are an effective way for the Maternal and Child Health Bureau (MCHB) to directly interact with state and local health departments and address programmatic changes, issues, and share success and lessons learned. This was my first national conference for US-based public health issues and it was wonderful to meet MCH professionals from all over the country. 

What were some of your favorite sessions/posters/presenters?
One of my favorite sessions was a skills builder session on "Implementing Universal Adverse Childhood Experiences (ACEs) Screening at a Community Health Center", led by a team from Santa Rosa Community Health Centers in California. I was struck by how they really seemed to "walk the walk" on the importance of mental/behavioral health as well as physical health. The panel represented three different clinics- a pediatrics clinic, a large hospital clinic and one located within a public high school, all part of the Community Health Centers in CA- all who have implemented universal ACEs screening.

The fundamentals seemed to be truly patient-centered and trauma-informed. They had signs up in all their waiting rooms that let clients know right away all would be asked these 10 questions and no one was being singled out for them. They had warm hand-offs with behavioral specialists for patients who screened high and would need further services. I thought it was especially interesting that the pediatrics clinic talked about how they ended up screening the parents of the kids as well sometimes and connected them with behavioral clinicians at sister sites.

Overall, I walked away feeling really inspired that this recognition of the importance of trauma and mental health has become a reality in this community.  

Was it everything you were expecting or did you hope to get something else out of the experience?
Similar to Salma, I really had no idea what to expect. For a first time attendee, I thought I got a lot of out of the conference (especially considering it was so quickly rescheduled after DC’s Snowpocalypse 2016!) I’ve only attended a handful of conferences and these bigger ones always feel a bit overwhelming. On the other hand, because they are so large, there are so many great presentations to choose from. I can say I was actually excited to go to all the workshops and seminars I signed up for!

Any takeaways?
There really aren’t any magic bullets for most of our public health challenges. I can only speak for myself, but I walked away feeling both tired and uplifted (which I know sounds very contradictory).

On the one hand- this work is so hard! Trying to address issues at a population level is rightfully complicated as communities are dynamic, living entities with so many intricate layers and pathways. There are no quick fixes for issues like poverty, racial inequities, or childhood trauma. It was uplifting to see shared recognition and universal concern over these issues in public health communities and honestly, relieving to see how everyone is struggling with how to successfully affect change.

What is the next conference you want to attend?
The next conference I am hoping to attend is another MCH focused one- CityMatch and MCH Epi in Philadelphia this September:


Tuesday, February 23, 2016

Ashley Kraybill, MPH
Wisconsin Population Health Service Fellow
Wisconsin Division of Public Health
Madison, WI

Hester Simons, MPH
Wisconsin Population Health Service Fellow
Wisconsin Division of Public Health
Centro Hispano of Dane County 
Madison, W

 On February 7, 2016, we observed the 16th annual National Black HIV/AIDS Awareness Day (NBHAAD), a national initiative aimed at mobilizing communities around HIV testing and treatment in response to the growing HIV and AIDS epidemic in African American communities. Many organizations and people who participated on this day work every day to increase HIV education, testing, community involvement, and treatment among black communities. As Population Health Service Fellows, we have learned about various initiatives around Wisconsin that aim to address these issues.

But, why is this so important?

National Data[1]
·       African Americans are the racial/ethnic group most affected by HIV.
·       The rate of new HIV infection in African Americans is 8 times that of whites based on population size.
·       Gay and bisexual men account for most new infections among African Americans; young gay and bisexual men aged 13 to 24 are the most affected of this group.

Wisconsin Data (2014)[2]
Of the 226 new cases of HIV infection diagnosed in Wisconsin during 2014:

Reflecting national trends, young Black men who have sex with men (MSM) in Wisconsin continue to be the population most affected by HIV in Wisconsin. During 2014:
  • Young Black MSM accounted for almost one-quarter (22%) of all new diagnoses in Wisconsin.
  • Diagnoses in young Black MSM more than doubled from 2005 to 2014.

 City of Milwaukee Data (2014)[3]
  • Milwaukee is disproportionately affected by HIV, as it makes up just 10% of the state’s population yet has 53% of all statewide HIV diagnoses.

  • 2 in 5 Black MSM in Milwaukee are living with HIV

  • Reflecting national trends, young black MSM in Milwaukee continue to be the population most affected by HIV. One-third of new HIV diagnoses in Milwaukee occurred in Black MSM ages 13-29.

When considering health outcomes data, especially disparities data, it is important to consider the context in which people live. 
  • Wisconsin ranks last in the country in the overall well-being of Black children based on  an index of 12 measures that gauge a child's success from birth to adulthood.[4]
  • Milwaukee is the most racially segregated large city in the United States.[5](see map below) 
  •  While the infant mortality rate has dropped in Milwaukee in recent years, it remains among the highest of the nation’s big cities.[6]  The infant mortality rate is commonly accepted as a measure of the general health and well-being of a population.[7]     
  •  4 in 10 Blacks in Milwaukee live in poverty, compared to 1 in 3 Hispanics and 1 in 7 Whites.[8]  
  •  45% of Black adults have completed some college or more education, compared to 29% of Hispanics and 64% of Whites.[8]  

In a recent article, “5 Reasons Why HIV Disproportionately Affects Black People,” there is an excellent discussion about the social determinants of HIV:

“The question is why? Why do black people carry the burden of this disease, especially when it didn't start out that way? The easy answer would be to say that black people engage in riskier behavior so therefore they are more likely to contract HIV. While personal responsibility is now and always a factor, black populations do not engage in risk behaviors at any higher rates than other races and ethnicities. This gives way to the fact that there are broader concerns that make HIV significantly more difficult to face and overcome in black communities.”[9]

In the face of these challenges, the NBHAAD initiative leverages a national platform to educate, bring awareness, and mobilize the African American community to:
Get Educated about HIV and AIDS;
Get Involved in community prevention efforts;
Get Tested to know their status; and
Get Treated to receive the continuum of care needed to live with HIV/AIDS

So what’s happening in the Fellowship around these issues?
Hester Simons, a second year fellow, is placed with both the Minority Health Program at the Wisconsin Division of Public Health and with Centro Hispano of Dane County. We sat down to discuss her work around HIV/AIDS.

Ashley: What are you doing in the fellowship related to HIV/AIDS?

Hester: Through my placement with the Minority Health Program at the Wisconsin Division of Public Health, I had the opportunity to participate in writing a grant last spring to address the Healthy People 2020 Leading Health Indicator HIV-13: Knowledge of serostatus among HIV-positive persons.[10] This grant is a joint initiative between the Minority Health Program and the AIDS/HIV Program. The overall goal of the grant is to reduce the disparity in AIDS/HIV cases among African American, Hispanic/Latino, and American Indian communities in Milwaukee, Wisconsin by increasing knowledge of serostatus among HIV-positive persons in these communities. Basically, we want to make sure people who have HIV are aware of their infection so they can receive the necessary treatment.

Ashley: How does this grant relate to National Black HIV/AIDS Awareness Day?

Hester: One of the objectives to reach the grant’s goal is to increase the number of people among the target populations (Black, Latino, and Native American) reached through HIV awareness events. This year, the grant will support five HIV awareness days, the first of which was NBHAAD.

Ashley: What did this awareness day look like?

Hester: NBHAAD was celebrated in Milwaukee on February 8th at Milwaukee Area Technical College (MATC) in the Student Center. The goal was to bring the information and services to people rather than asking them to come to the services. This was a collaborative effort put on by UMOS and several other organizations. It was estimated that more than 1,000 people came to the event and received information. Testing for HIV and sexually transmitted infection (STI) were provided for free and 3,500 condoms were distributed. Almost 50 people were tested for HIV and almost 40 were tested for STIs.  The success of this event was clearly a result of the hard work and thoughtful collaboration of the partners involved.

Ashley: What has your experience been like as a fellow working on this project?

Hester: This project has been a great learning experience! I’ve been given the opportunity and support to take a lead role in the writing of the grant application and its subsequent implementation. It has also given me the opportunity to merge my passions for health equity and HIV. The first six months of the grant have involved a lot of planning and figuring out how we can make the best use of the resources available through this grant. Two important elements that we continue to build into our implementation plans are 1) the need to evaluate our efforts and adjust them accordingly and 2) the need to elicit feedback from the groups we hope to reach with our work and those who are most affected by HIV.

Ashley: Thank you so much for all the work you have done and for telling us about it!
Want more information?
Wisconsin Minority Health Program website:
Wisconsin AIDS/HIV Program website:
CDC’s HIV surveillance web page:
General Information about HIV prevention and care services in WI:
Blog Post: “Hunted by the State: HIV, Black Folk & How Advocacy Fails Us”


[2] Wisconsin AIDS/HIV Program (2015). Summary of the Wisconsin HIV/AIDS Surveillance Annual Review: New Diagnoses, Prevalent Cases, and Deaths Reported through December 31, 2014. Retrieved from
[3] Wisconsin AIDS/HIV Program (2015). Wisconsin HIV/AIDS Surveillance Annual Review 2014 – Addendum: City of Milwaukee. Retrieved from
[4] Annie E. Casey Foundation, Race for Results, 2014 (using 2010-2013 data).
[5] The Persistence of Segregation in the Metropolis: New Findings from the 2010 Census. JR Logan and BJ Stults, March 24, 2011 (using 2010 census data).
[6] Annie E. Casey Foundation, Kids Count, 2014 (using 2013 infant mortality from CDC).
[7] CDC Infant Mortality fact sheet.
[8] American Community Survey, 2010-2014 Estimates.