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: http://www.nerdreport.com/2015/08/06/fantastic-four-movie-review-paved-with-good-intentions/

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:

Understanding Implicit Bias

Can you Overcome inbuilt bias

Unpacking the Invisible Knapsack by Peggy McIntosh

Miles to Go Before We Sleep: Racial Inequities in Health by David Williams

Toward a Cultural Consciousness of Self in Relationship: From “Us and Them” to “We” by William Ventres and Cynthia Haq

White Fragility: Why It’s So Hard to Talk to White People About Racism

How Do We Advance Health Equity?

Evelyn Sharkey, MPH, MSW
Wisconsin Population Health Service Fellow
City of Milwaukee Health Department 
Milwaukee, WI

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


“How can professionals dedicated to improving health continue our traditional roles of promoting healthy behaviors and delivering quality health care and also balance our repertoire by adding the skills, competencies, tools, and methods to address the socioeconomic policies, systems, and environments that so strongly influence health?” (p. 218)

Dr. Geof Swain, founding director of the Wisconsin Center for Health Equity, and former Fellows Katarina Grande (2010-2012 cohort), Carly Hood (2012-2014 cohort), and Paula Tran Inzeo (2010-2012 cohort) ask this question to frame their commentary published in the December 2014 issue of the Wisconsin Medical Journal, posing a dilemma that confronts physicians and other health care professionals on a daily basis as they care for patients. 

Determinants of health, from Dahlgren & Whitehead (1991), as cited in Exworthy (2008)

Before getting into the authors’ suggestions for overcoming this dilemma, let’s get some background on the broader issues addressed in the commentary:  health and the things that make people and communities more or less healthy.  According to the World Health Organization (WHO), health is more than just not being sick; rather, it’s “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”¹  Overall health is influenced by various factors known as “health determinants,” which include not just health care, but also genetics and biology, individual behaviors, social and economic conditions, and the physical environment.^2,3  Most of these determinants are “modifiable” in the sense that it’s possible to change or control them, including health care, individual behaviors, social and economic factors, and the environment.  However, it’s not yet possible to significantly alter an individual’s genetics and biology.  It’s also important to note that many of these determinants are external to an individual, including health care, social and economic factors, and the physical environment.

The Rankings model of modifiable health 

factors that impact community health 

(County Health Rankings, 2014).

The social, economic, and physical environment conditions that affect a person’s health are known as the “social determinants of health.”⁴  You can think of these determinants as “the conditions in which people are born, grown, live, work and age.”^2,5,6 Examples of various social determinants of health from Healthy People 2020 include “the resources and supports available in our homes, neighborhoods, and communities; the quality of our schooling; the safety of our workplaces; the cleanliness of our water, food, and air; and the nature of our social interactions and relationships.”⁴

As Swain et al. point out, almost all of the health-related funding in the U.S. is geared towards improving access and quality of health care services.  While health care is undoubtedly important, there is a great deal of evidence that social and economic factors and the physical environment may actually have a stronger impact on health.  This is shown by one model of the impact of health determinants developed by the County Health Rankings & Roadmaps program.  This program is a collaboration between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute, which created the model to estimate the relative contribution of modifiable health determinants.⁷  Biology and genetics are not modifiable and are therefore not included.

What does the Rankings model show?  First, 50% of the modifiable factors that influence health are social determinants of health.  If you dig deeper into this 50%, you can see that the influence of social and economic factors is especially strong, accounting for 40% of the factors that impact health.  Based on this, it’s clear that people who seek to promote health should address these social and economic influences.  However, according to Swain et al., there is limited guidance as to how physicians and other health care professionals and health systems can actually go about doing this.  This may be why more than 80% of U.S. physicians think unmet social needs negatively affect health but do not feel capable of addressing the social needs of their patients.⁸ 

Through exploring two social determinants of health that have been studied extensively—income/employment and education—Swain et al. review evidence-based examples of both clinical and policy-level actions that health care professionals can take to address social determinants.  They conclude their commentary by providing concrete and actionable suggestions and resources for addressing income/employment, education, and other socioeconomic factors that influence individual and community health.  At the clinical level, the authors suggest health care professionals screen for socioeconomic issues like food and employment during clinical visits and coordinate their services with social workers, community health workers, and others.  At the population level, suggested strategies include advocating for social and economic policies that promote health, working collectively with peers and professional associations; and being “both patient and persistent” (p. 220).

This is a helpful article for anyone interested in promoting the health and well-being of both individuals and communities, and it was excellent foundational reading for the fellowship’s February monthly meeting on health equity.  Fellows were joined at this meeting by students from the TRIUMPH program.  TRIUMPH, which stands for Training in Urban Medicine and Public Health, is a program for 3^rd and 4^th year medical students at UW Madison’s School of Medicine and Public Health.  The program integrates clinical medicine with community and public health and aims to provide medical students with the knowledge and skills needed to promote health equity and reduce disparities.

During the meeting, attendees learned about The National Equity Atlas, a new policy and data tool that can be used to make the economic case for equity.  The Atlas includes data from all 50 states, Washington D.C., and the largest 150 metropolitan statistical areas in the U.S. (including the Madison and Milwaukee metropolitan areas).

A picture depicting the difference between
“equality” and “equity,” featured in the February meeting
presentation by Angela Russell and Jordan Bingham.  
Source:  City of Portland Office of Equity and Human Rights

In the afternoon, fellows and TRIUMPH students participated in an in-depth conversation on health equity strategies for public health and medical professionals led by Dr. Geof Swain. They wrestled with the difference between equality and equity and discussed frameworks for thinking about how the social determinants of health lead to health disparities. The day ended with an engaging presentation by Angela Russell and Jordan Bingham, Health Equity Coordinators from Public Health Madison Dane County, on how to talk to policy makers about health equity. 

Sources:
¹WHO Definition of Health. World Health Organization Website.  http://www.who.int/about/definition/en/print.html. Accessed February 11, 2015.
²McGovern L, Miller G, Hughes-Cromwick P. Health Policy Brief:  The Relative Contribution of Multiple Determinants to Health Outcomes.  Health Affairs. August 21, 2014. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=123. Accessed February 11, 2015.
³The Determinants of Health. World Health Organization Web Site. http://www.who.int/hia/evidence/doh/en/. Accessed February 11, 2015.
⁴ Healthy People 2020. Social Determinants of Health. http://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health. Accessed March 6, 2015.
⁵Braveman P, Egerter S, Williams DR.  The Social Determinants of Health:  Coming of Age.  Annu Rev Public Health.  2011;32:381-98. doi:  10.1146/annurev-publhealth-031210-101218. http://www.ncbi.nlm.nih.gov/pubmed/21091195. Accessed February 11, 2015.
⁶Social Determinants of Health. World Health Organization Web Site. http://www.who.int/social_determinants/en/. Accessed February 11, 2015.
⁷About the Program. County Health Rankings & Roadmaps Web Site. http://www.countyhealthrankings.org/about-project. Accessed February 11, 2015.
⁸Goldstein D, Holmes J. 2011 Physicians’ Daily Life Report. Harris Interactive.  Prepared for the Robert Wood Johnson Foundation. November 15, 2011. http://www.rwjf.org/content/dam/web-assets/2011/11/2011-physicians--daily-life-report. Accessed February 11, 2015.

The Fellowship as a Learning Community

Lauren Lamers, MPH

Menominee Tribal Clinic

Keshena, WI

One of the unique things about the Population Health Service Fellowship is that it is truly intended to be a learning community.  Earlier this year, fellows, faculty, and preceptors had the opportunity to discuss and outline exactly what we wanted our learning community to look like.  Some of the characteristics we thought were important to include as guiding principles for our community included:

·         Recognizing and valuing the different perspectives that all members of the learning community bring to the group 

·         Creating safe spaces to share questions, opinions, ideas, and constructive feedback

·         Supporting each other to take chances, celebrating each other’s strengths, and advocating for each other

·         Engaging with others in the community to enhance our own and others’ learning

·         Being committed to long-term, ongoing learning and self-improvement

The true value of the fellowship learning community, however, is that these principles are not merely words on a page - they play an integral role in our projects, meetings, and interactions with each other.  This was particularly apparent during our annual overnight retreat in Shawano and Menominee Counties earlier this month.  Other than being an exciting opportunity to show off my placement sites, one of my biggest takeaways from the meeting was just how many ways fellows, faculty, staff, and preceptors exemplified the values we set for ourselves as a learning community.    Here are just a few of those examples…

The group touring Keshena Falls, Menominee County/Reservation, WI

Our meeting, like each of our monthly meetings, started with time for fellow updates.  I was (and always am) so impressed at the fantastic work everyone is doing.  It’s truly inspiring to be part of such a passionate, talented, and dedicated group.  Having the opportunity to be inspired by each other has, for me, been one of the best parts of the fellowship learning community.

Throughout the meeting, everyone was actively engaged.  Fellows and faculty alike brought enthusiasm to learning more about our meeting topics (American Indian health and farm health).  There was great discussion and thoughtful questions for our speakers, and while the speakers themselves brought fantastic perspectives to our meeting, I think we learned just as much by engaging with each other around the topics we were discussing.

Another staple of our monthly meetings is the CALs presentation, when one fellow presents on a project they’ve done and how it helped develop their core areas of learning.  In this case, I was the one presenting.  I so appreciated the interest that everyone showed, the great questions that opened up deeper discussion and challenged me to think about my project differently, and the supportive atmosphere that helped me feel comfortable talking about not only what I thought went well, but also things I could have done better.  Having this safe space within our learning community to talk about our fellowship experiences has been so beneficial for growing both personally and professionally.

A little fellowship team building time.

Finally, one of the strongest aspects of the fellowship learning community is the varied expertise and insights that everyone brings to the table.  There were a few stellar examples of this at our retreat.  One was when second-year fellows Mallory Edgar and Crysta Jarczynski facilitated a skill building session about community readiness assessments – a topic on which they’ve developed quite bit of expertise through their fellowship projects.  They did a fantastic job not only presenting, but also developing interactive ways for us to see how readiness assessments could be useful in our own work.  Another example that really resonated with me was the insight, wisdom, and experience that my preceptor Faye Dodge, brought to our discussions around American Indian health.  For me, this exemplified the invaluable contributions that all of us – fellows, faculty, staff, and preceptors - make toward building the fellowship community.

 All of these are just a few examples of what makes our fellowship a true learning community.  What I think makes it truly special, though, is that this commitment to sharing our learning and to supporting and challenging each other to grow isn’t confined to our monthly meetings – it’s a culture we’ve built.  Being part of this community has been one of the best parts of my fellowship, and it’s an experience for which I am profoundly grateful. 

Monthly Meeting Reflections: Transgender 101

e.shor, MPH

Population Health Service Fellow

HIV/AIDS Department, Division of Public Health

Madison, Wisconsin




I promised I would update you on the transgender 101 portion of our last monthly meeting! I don't break promises.

For our skill building section of the meeting we learned about gender identity & transgender identities. There are a lot of reasons we did this:

• It is important
• People in your life and in your workplace may identify as transgender
• Gender is a part of life that impacts EVERYONE
• Everyone has a gender identity
• It is respectful to use the correct name and pronouns for people
• I respectfully demanded that we do it :)

There are many ways to define transgender and it can be very personal to some to define it for themsleves. That being said, transgender often refers to a person whose gender identity is different from the sex they were assigned at birth. Let's unravel some of this a little more...

 

I bet you are wondering...what does this mean for me?

 

 

Well...more likely than not you probably know some who identifies as transgender, and even if you do not, it is still important to be respectful of everyone you meet by not making assumptions you know anything about their gender identity based on their gender expression or biological sex.

 

Practically this means, asking HOW someone prefers to be called. For example, my name is e.shor and I prefer to be called by that name or shor, and I also prefer that you use my name or gender neutral pronouns like they/them/their. Here is how to talk about me: Did you see that awesome new haircut e.shor has. I wonder if they went to the salon on Willy St. or if they got their haircut by a friend?

 

Now, the hardest part about this for many people is reframing how you conceptualize gender altogether. We are often socialized in our homes, schools, places of worship to see gender as binary (male or female) and inextricably linked to sex. Think about all the things that you have been taught about gender in your life...

 

So you are probably wondering now...well why is this on a public health blog?

 

There are many reasons. One of which is that transgender health is a public health issue and a health equity issue.

 

More on that another time...

Monthly Meeting Reflections: Health Equity & Transgender 101

 

e.shor, MPH

UW Population Health Service Fellow

HIV/AIDS Program, Department of Public Health

Madison, Wisconsin





On September 3rd the fellows, preceptors, and staff had our first monthly meeting for this "year" ...we kinda roll on our own timeframe. Our topic for this monthly meeting was health equity and for our skill building we discussed transgender 101. We had quite an epic day full of learning, games, and applying a health equity lens to our work.

Maybe you are thinking... oh my, what is health equity? I've heard this somewhere...but I can't put my finger on it.

There is no simple answer to this question...nor is there a simple solution. I am going to try my best here to explain health equity and link you to some resources.

Health equity does not exist in a vaccuum...it is intimately linked to health disparities and health inequities. It is important to have an understanding of all of these things and social determinants of health (SDOH) to truly understand health equity. So let's start with social determinants of health...they are:

"The complex, integrated, and overlapping social structures and economic systems that are responsible for most health inequities. These social structures and economic systems include the social environment, physical environment, health services, and structural and societal factors. Social determinants of health are shaped by the distribution of money, power, and resources throughout local communities, nations, and the world" (World Health Organization 2008)

Here is a picture to help understand SDOH (there are lots of cool pictures of SDOH if you google it):

Illustration from Anthony B. Iton. "The Ethics of the Medical Model in Addressing the Root Causes of Health Disparities in Local Public Health Practice."

 So we know there are all these SDOHs out there impacting health...what happens next? These big structural systems make it easier for some people to have good health outcomes and they make it harder for others to have good health outcomes. This is health inequity. CDC (Centers for Disease Control) describes health inequities as:

A difference or disparity in health outcomes that is systematic, avoidable, and unjust

Then what is a health disparity? How is it different from health inequity? Good question smart reader...a health disparity is:

Variations or differences in health status among groups of people. This may refer to any difference in health, with no implication that these differences are unjust (American Medical Students Association)

A key workd that has cropped up a few times for us is unjust. This makes health a social justice issue. Social Justice refers to an equitable distribution of social, economic, and political resources AND when there is an unequal distribution of resources and opportunities is manifested through inequitable access and exposure to social determinants of health. Full circle.

Finally, that means health equity is:

When all people have the opportunity to "attain their full health potential and no one is disadvantaged from achieving this potential because of their social position or other socially determined circumstance" (CDC 2012, Braveman 2003)

This is just a brief overview of some things related to this ginormous area of public health. It is also an incredible shift in the way we approach public health and the world. Health equity is a frame of mind (and a science!) that is supposed to help us put context to the forces in the world that unjustly impact people's health. It is something that you have to believe in...and, ultimately, what we all have to work towards in our public health work.

And now onto Transgender 101...oh wait, maybe that is for next time :)

 

Meeting: Tribal Health

Geof Swain, Medical Director and Chief Medical Officer for the Milwaukee Health Department, as well as Preceptor for Fellows placed in Milwaukee, explains his drawing during an introductory activity in Keshena, Wisconsin

September's two-day monthly meeting on Tribal Health was held in Keshena, WI.  This meeting kicked off with an introduction activity, in which fellows and fellowship staff were asked to draw/write three things that represented their culture. 

David Grignon, Director of Historic Preservation for the Menominee Indian Tribe of Wisconsin, gave an overview of the termination and restoration of the Menominee Tribe.  Later, we heard from Jerry Waukau, Health Administrator of the Menominee Tribal Clinic, and Wendall Waukau, Superintendent of Schools for the Menominee Indian School District.  Jerry and Wendell gave an inspiring talk about community engagement and discussed how they raised their high school graduation rate from around fifty percent up to ninety-five percent.

Fellows and fellowship staff spend time sharing stories and roasting marshmallows over a campfire

Later that evening, fellows and fellowship staff spent time bonding over a campfire and making smores.  One of our fellows, Erica LeCounte, even ate her very first smore.

First Year Fellow, Erica LeCounte eating her very first smore

Day two began with Kristen Audet, second year fellow, who gave an awesome CALs presentation on the emergency response to the heat wave that occurred this past summer.  Then, Kristin Hill, Director of the Great Lakes Intertribal Epidemiology Center, gave the Fellows an overview of Indian Health Services.

Isaiah Brokenleg shares some of the culture and history of the Menominee tribe with the fellows

This was followed by Isaiah Brokenleg, Epidemiologist and Program Director with the Great Lakes Intertribal Epidemiology Center, who instructed the fellows on "Indian 101" which discussed the history and culture of the Menominee Tribe.  Lastly, the fellows participated in an activity which served as a lesson on the privilege that many people are unaware that they have, but that continually affects their everyday lives. 

One last group shot

Meeting: Refugee and Immigrant Health

Abdistaar Doon, Refugee Services Assistant with Workforce Resources Inc. speaks to the group as Fellow Akbar Husain listens. Here, Doon shows the group a traditional toothbrush from Somalia.

April's monthly Fellowship meeting, held in Eau Claire, focused on refugee and immigrant health. Abdistaar Doon, Refugee Services Assistant from Workforce Resources Inc., spoke to the group about life in Somalia prior to arriving in the U.S. as a refugee. 

We discussed the book, Enrique's Journey, UW-Madison's 2011 Go Big Read selection. Fellows and staff had mixed reactions to the book, which chronicles the treacherous journey of a young man from Honduras to America. 

Fellow Tyler Weber shared his experiences with the Lindsay Heights Neighborhood Community Research Council for his Core Activities of Learning (CAL) presentation. One or two Fellows give CAL presentations at each monthly meeting. Here, Tyler demonstrated the CALS of Leadership, Community Dimensions of Practice, Cultural Competency, and Communication.

Fellow Tyler Weber presents his work with the Lindsay Heights Neighborhood Community Research Council

Quality Improvement Training

Fellow Katherine Vaughn-Jehring works on a QI exercise

Fellows gathered in Eau Claire, Wisconsin, for a day-long training on Quality Improvement. Led by Fellow alumna Kate Konkle, the group learned numerous techniques for improving processes. 

Meeting: Homelessness and public health

Brochures from Pathfinders and Walker's Point Youth and Family Center

Fellow Rashonda Jones planned an intense meeting on the topic of homelessness. To prepare for the meeting, we watched a Milwaukee Public Television documentary called "Homeless in the Heartland"--here's the link: http://www.youtube.com/watch?v=YCHfB4aui9g  

Sexuality and Empowerment

Rep. Tammy Baldwin (D-WI) in an LGBT Equality Caucus video for the It Gets Better Project. Image from ItGetsBetter.org; http://www.itgetsbetter.org/video/entry/7577/

For the first time, we held a joint monthly meeting with the Training in Urban Medicine and Public Health (TRIUMPH) medical students. The meeting focused both on public health and medical aspects of LGBT health. 

Public Health Preparedness

Radio coverage areas in Wisconsin: important for public health preparedness

<<Alert: train derailment/toxic chemicals on board/major spill<< 

Food security and nutrition

Fellows visited SHARE Wisconsin, a food-buying club committed to making affordable food available to both areas undeserved by traditional grocery stores (areas known as "food deserts") as well as anyone interested in saving money. We began our day with a volunteer project, which mirrors the operational model of SHARE--highly volunteer-run. We packed 436 boxes of organic produce for SHARE clients (and had a great time doing it)!

Tyler, Anneke, Emma, Paula, and Jim work the assembly line

Policy and Public Health

Fellows and staff at the Wisconsin State Capitol

Fellows spent a day learning about the link between public health and policy. The meeting, organized by Emma Hynes and Katherine Vaughn-Jehring, included a mini-workshop on analyzing health-related legislation, a tour of the State Capitol building, a meet and greet with Wisconsin State Senator Fred Risser, and a meeting with Department of Health Services Executive Assistant Kevin Moore.

Rural Health and Tribal Health

Fellows roadtripped north to Lac du Flambeau, Wisconsin, for the annual Tribal Health and Rural Health meeting. Kristin Hill, Director of the Great Lakes Inter-Tribal Epidemiology Center, provided an Indian Health Services overview, which detailed the Trust Responsibility to provide health care, an agreement between the federal government and tribes to provide healthcare for all American Indians.

Racism, Power, and Privilege

The Fellows discussed the deeply important issues of racism, power, and privilege's impact on public health. The day started with a session from representatives from The Office for Equity and Diversity. Discussions that followed centered on: 

• A Gardener's Tale
• Unnatural Causes: When the Bough Breaks
• Tackling the Root Causes of Health Disparities through Community Capacity Building 

Tyler and Paula, the meeting organizers, stop by Memorial Union's Terrace after an intense day of discussion.