Friday, December 23, 2016

Your Winter Reading List: 9 Books for the Public Health Bookworm

As 2016 winds down and we settle into the cold weather months here in Wisconsin, those of us in the learning community thought now would be a nice time to share some suggestions for your winter reading lists. Whether you find yourself wanting to curl up next to the fire or you’re looking for a good read during those holiday travels, read on for recommendations of books that have inspired, informed, and challenged thoughts on public health issues ranging from housing, to data, to bias.$2.00 a day: Living on Almost Nothing in America
by Kathryn Edin and H. Luke Shaefer                                
Recommended by Fiona Weeks, First Year Fellow 

I wouldn't say I "love" this book because it does inspire some serious discomfort around the realities of poverty in the United States. I also wouldn't say I love it because I don't necessarily agree with all of the interpretations or recommendations of the book. On the other hand, you could say I love it for these very same reasons. It sparks critical thinking and debate about the very essence of poverty and what it would mean to win the war on poverty. You should read this book if you think you know what poverty looks like; if you care about each person having the opportunity to live her life with dignity; or if you have any interaction with or work related to SNAP, WIC, TANF or other anti-poverty programs. This book opened me up to the importance of individual autonomy for family well-being and the real significance of sending the message through public policy that we trust individuals and parents to make smart decisions for their families. Poverty is perhaps THE most important social determinant of health. If you don't believe me, read the book.

Recommended by Stephanie Richards, Fellowship Program Lead

I couldn't put it down-- it was such an engaging read and also incredibly informative. If you're interested in housing policy, you should read this book. It helped me understand more about all that is working against poor, African American, people with disabilities, and other oppressed groups, particularly housing and law enforcement policies. This book was the UW Go Big Read book and I'm pretty sure I gave everyone in the learning community a free copy!

by Nicholas Kristof and Sheryl WuDunn
Recommended by Stevie Burrows, First Year Fellow

This book is phenomenal because it gives the reader a vivid look into the oppression and de-humanization of women in the developing world; however, it does so while simultaneously highlighting the women's intelligence, resilience, and determination to change their communities. In our world today--with constant media coverage-- it is easy to become desensitized to the suffering of others, but this book opened my eyes. It fostered in me a deep respect for these brave women and made me want to effect change in my own community. This book truly transcends a multitude of public health topics, but you should really read this book if you care about women's health, rural health, and global health. It also contains great illustrations of how social and economic factors, such as education, can improve the health of individuals and communities.

by Bryan Stevenson
Recommended by Salma Abadin, Second Year Fellow

This book personalizes the difficulties of inequities through storytelling - both from the perspective of being the one who experiences them and then from the side of the person attempting to dismantle them. While you quickly realize how disheartening this work can be, Stevenson creates hope and resilience in the midst of adversity. The quote from this book, or maybe it's from when I've seen Stevenson speak, that has stuck with me is "Each of us is more than the worst thing we've done." Imagine what that would look like if we all believed this? It's made me think more about respect, dignity, and what a fair and inclusive society actually looks like. Throughout this book, there is a clear call to action that the evolution of our criminal justice system to its present state affects all of us and it will take all of us to overcome it. Public health has the opportunity to provide a framework, lens, or even a goal for what we'd like the criminal justice system to be. It moves away from individual culpability to community action.

by Nate Silver
Recommended by Nick Zupan, Second Year Fellow

This is a book on using data to make decisions and predictions. I think it’s great because it goes into using stats and analytics to make predictions, but also breaks down a number of fallacies in relying too heavily on data. If you’re a data geek like me and want to learn more about modeling, forecasting, and probability, you should check out this book. After reading it, I think I have a better understanding of how to utilize data for public health practice. I also learned some of the pitfalls of over-analyzing data. A data-informed or evidence-based approach is crucial to providing high quality public health programming and services. This book sheds light on how to extract the “story” in the data.

by Anne Fadiman
Recommended by Britt Nigon, First Year Fellow

If you’ve ever wondered about how the US medical system is perceived by those who are not familiar with it, or if you’re interested in thinking about bias in healthcare, this book is worth a read. It got me thinking more about historical trauma, medical anthropology, and the value of culturally-informed practice. It also opened my eyes to the realities of resettled populations and offered different ways of thinking about what happens when two cultures meet. To quote the author, “Our view of reality is only a view, not reality itself.”

by Elizabeth Pisani
Recommended by Leslie Tou, Second Year Fellow

You should read this book if you like reading nonfiction! Because even though it's from an epidemiologist and about public health- it's a fascinating read. It opened me up to how murky data is in reality and what the world is like for a sex worker.

by Daniel Kahneman
Recommended by Geof Swain, Medical Director and Chief Medical Officer, City of Milwaukee Health Department (MHD), site preceptor and MHD liaison

You should read this book if you care about human behavior and decision-making. To quote a review by Larry Swedroe of CBS News: Kahneman “clearly shows that while we like to think of ourselves as rational in our decision making, the truth is we are subject to many biases. At least being aware of them will give you a better chance of avoiding them, or at least making fewer of them.” A colleague of mine characterized it as "the most important book in the last decade, maybe more.”

by Dan Fagin
Recommended by Maria Mora, Preventive Medicine Resident

This book is very engaging and describes a world before the EPA and environmental regulations. You should pick it up if you would like to discover how corporations affect the environment, and how those regulations benefit you even if you don’t know it. It made me care more about risk communication and covered policy implications as well as the role of public health and the government in healthcare. It also contains a lot of history about epidemiology and public health – John Snow and more!

Note: This post is comprised of recommendations based on personal opinions and is not endorsed by any of the authors, publishers, or distributors referenced here. These thoughts are those of our learning community and do not represent the institutions or organizations associated with the fellowship. The views or opinions expressed in this post are not intended to malign any religion, ethnic group, organization, or individual.

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: