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. 

'In Closing'

Lindsay Menard, MPH

La Crosse, Wisconsin

As my final weeks of being a Wisconsin Population Health Service Fellow draw near, I have had the opportunity to reflect upon the past 22 months and recognize how much I have grown and how fortunate I am to have been part of such compassionate, innovative, and inclusive communities.  I want to use this blog post to focus on one of those communities, the La Crosse County Health Department, by highlighting one particular project I helped advance, the accreditation process.The accreditation journey has fostered my professional and personal development during my time as a Wisconsin Population Health Service Fellow.

Getting Started

Almost two years ago, the only thing I knew about national voluntary public health accreditation was that the Public Health Accreditation Board (PHAB) had released a set of standards and measures in 2011 to help state, local, and tribal health departments ensure the three core functions of public health and the ten essential health services were being met.   I had to quickly get myself up to speed on the purpose of accreditation (with the use of resources such as: the PHAB Online Orientation, Embracing Quality in Public Health: A Practitioner’s Performance Management Primer, and Developing a Local Health Department Strategic Plan: A How-To Guide), the reasons the La Crosse County Health Department was pursuing it, and how I could add value to the process. 

Lessons Learned

The first lesson I learned is that people and organizations always have room for improvement, and that it is important to introduce quality improvement efforts in a way that does not threaten staff or the good work they were already doing.  I framed this concept in many different ways.  For example, when discussing performance management and quality improvement ideas (Domain 9 in the standards and measures established by PHAB) with public health nursing staff I highlighted the fact that we are already reaching a large proportion of the community with seasonal influenza vaccinations, and then asked them to think about how we could reach even more people and improve upon the structure of community influenza clinics.

I have also learned to be open to change, to document change, and to encourage change (even if I am hesitant about it myself).  Change does not come easily to most people, including me.  Learning how to maneuver change, address change resistors, and embrace change has been important throughout the accreditation process.  We, the La Crosse County Health Department, had to overhaul and develop new systems.  Changing the infrastructure of an organization is no easy task.  It took time, patience, and various forms of training to get new or changed systems to “stick.”  And as a new employee and  Wisconsin Population Health Service Fellow, I was essentially charged with testing the status quo.  I had to learn to build rapport and earn the trust of staff.  There was a period during the transition when everyone (including me) had to adjust to the shift in the organizational structure. 

The third lesson I learned was how important communication is at all levels of an organization, not just at a local health department.  It is important for leaders to communicate on a regular basis with all staff members and it is equally important for leadership to explicitly reach out to staff for feedback.  Communicating thoughts, ideas, improvements, and questions can be extremely difficult.  Encouraging a safe environment for all to communicate is essential.  Otherwise, trust and morale break down. To communicate with staff about the new systems, plans, and policies and procedures (P&Ps) that were created, adopted, and implemented a department newsletter was created (Figures 1 and 2).  The newsletter highlights the accreditation process, discusses the twelve domains developed by PHAB, states new changes, and captures health department news.   Through the accreditation process, I have learned to develop newsletters and frame messages for staff and the media in a meaningful and concrete way. 

Figure 1:                                                  Figure 2: 

     

Final Thoughts

In closing, the accreditation process has increased the capacity of the La Crosse County Health Department to deliver the ten essential services AND it has made me a better public health professional.  I have increased my knowledge of public health, fostered many professional skills, learned to manage change, and recognized the value of communication throughout an organization.   I will carry the many lessons and skills I have learned throughout the Fellowship program with me for the rest of my career.  Fellowship faculty and staff explain it best, “Through this intensive process, academic health departments and their UW School of Medicine and Public Health—based partners have developed a way to take talented and highly motivated early-career professionals and transform them into confident, emerging leaders, with cutting-edge skills, competencies, and connections to improve population health outcomes and advance health equity in Wisconsin and beyond.”[i] I am proof.  I have been transformed.

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[i] Ceraso, M., Swain, G.R., Vergeront, J.M., Oliver, T.O., & Remington, P.L. (2014). Academic Health Departments as Training Sites for Future Public Health Leaders: A Partnership Model in Wisconsin.  Journal of Public Health Management and Practice, 20 (3), 324-329.

A Major Achievement: The Healthiest Wisconsin 2020 Baseline and Health Disparities Report

                                     

 
  e.shor, MPH and Christina R. Hanna, MPH
  Population Health Service Fellows
  HIV/AIDS Program, Division of Public Health
  Madison, Wisconsin

Over the past few years, many Fellows and staff at the Wisconsin Department of Health Services (DHS) have been working to put together the Healthiest Wisconsin 2020 Baseline and Health Disparities Report. The report serves both as a baseline report for Healthiest Wisconsin (HW) 2020, Wisconsin's state health plan, and as a report on health disparities in Wisconsin. Users can orient themselves to this large report by reviewing the text on the web page and the Executive Summary.

The report is organized into health focus areas, an infrastructure focus area focusing on access to high-quality health services, and data summaries by population. The health focus areas include:

• Alcohol and other drug use
• Chronic disease prevention and management
• Communicable disease prevention and control
• Environmental and occupational health
• Healthy growth and development
• Injury and violence
• Mental health
• Nutrition
• Oral health
• Physical activity
• Reproductive and sexual health
• Tobacco use and exposure

The data summaries by population highlight demographic and socioeconomic data for each population and emphasizes health risk behaviors and outcomes where that population experiences disparities compared to other groups. The populations highlighted in this report include:

• Blacks/African Americans
• American Indians
• Asians
• Hispanics/Latinos
• Lower socioeconomic status populations
• People with disabilities
• Lesbian, gay, bisexual, transgender populations
• Geography (rural, suburban, urban)

Fellows worked on many pieces of the report including writing SAS codes, running data, analyzing data, putting together the PowerPoint, and writing some of the chapters, editing, and evaluation. It was truly a team effort with over 60 contributors. The current and former Fellows that have contributed to this important report include Akbar Husain, Anneke Mohr, Erica LeCounte, Christina Hanna, Carly Hood, Lindsay Menard, Melissa Olson, Kelli Stader, and e.shor.

This report is unique is that it brings together a rich set of data on a diverse range of populations. Within the Wisconsin Division of Public Health, program areas have epidemiologists that collect, analyze, and present data specific to that area. For example, the HIV Program has staff members who collect and compile data and publish reports on HIV in Wisconsin. There is no one epidemiologist that is charged to compile data about racial and ethnic populations, LGBT people, and other marginalized communities and the health disparities that these communities face. A large number of people stepped out of their usual responsibilities to help put this report together. Another unique aspect of this report is that it highlights communities that are often left behind and do not get enough attention, especially given the extreme health disparities in Wisconsin. All of these factors make it incredibly important to get this report out to people working on these issues and working in these communities. If you think of someone who could benefit from the information in this report please send them the link and do your part in getting the word out!

Do Our Built Environment Redesigns Consider Health AND Equity?

Carly Hood, MPA, MPH

Population Health Service Fellow

Wisconsin Center for Health Equity

Health First Wisconsin

Wisconsin Division of Public Health

Madison, Wisconsin

Monday I attended the Population Health Sciences seminar “Retrofitting Suburbia: Urban Design for Public Health” given by Ellen Dunham-Jones who is a Professor of Architecture and Urban Design at the Georgia Tech School of Architecture. It was a great lecture with a wealth of insights on areas around the country that have undergone various methods of design to recover and invigorate the empty lots and strip malls blighting our nation. Such methods include everything from reinhabitation (repurposing of old buildings) and redevelopment (building new structures on old properties), to “regreening “or simply tearing things down to put in more space for trees, gardens and space to be active. (Archive coming soon!)

Somewhat counterintuitive and disturbing, I was surprised to learn that we have seen a dynamic shift in where poverty in our country exists, and today there are more poor people living in the suburbs than the cities (reinforced by this infographic).

This is in part the result of what’s known as the “drive til you qualify” phenomenon whereby if you want a shorter and cheaper commute, you have to be able to pay for it in home price (and vice versa). This lack of regulation on housing prices and affordability, as Professor Dunham-Jones pointed out, has led to uneven and unsustainable patterns in development as we see them today.

But it was as she shared pictures of a case study (one from her incredible database of 800 locales!) from my home state of Oregon that I got to thinking…not all suburbs are created equal. She was sharing changes made to a structure in a suburb of Portland called Lake Oswego which happens to have the greatest concentration of Portland-area homes worth more than $1 million. And so it struck me: Are the people in Lake Oswego the people most in need of retrofitting for the “public’s health?” Now I recognize that this is just one of many examples of a suburb that is reusing space for new purposes; some examples are found in impoverished communities, others in more well off areas. And Professor Dunham-Jones did share stories from both ends of the spectrum. But given that lower socioeconomic status has consistently been associated with poorer health outcomes (which holds across the income gradient), if one of the goals of “retrofitting suburbia” is to improve population health, wouldn’t we be more successful at achieving this goal if our efforts were more often targeted in areas with poor health, less community cohesion, and fewer options for safe shared space?  

There’s no doubt empty strip malls, large parking lots, and poorly designed suburban neighborhoods are not only eye-sores, but are contributing to our car-dependent and chronic-disease ridden country.

But should we be looking towards those with longest commutes, fewest parks, and/or highest rates of morbidity to consider such beneficial transformations? And even before we ask those questions, I’d explore just what may be occurring inside those communities that we can’t see from the outside…Kaid Benfield, Special Counsel for Urban Solutions at Natural Resources Defense Council, highlights, “As [suburban] properties have declined, so have their rents, making them affordable to small, often entrepreneurial businesses,” businesses often owned and frequented by inner-suburb immigrant populations. Says Benfield, “The risk is that, as we reshape these old properties with new buildings and concepts, the replacement properties will be much more valuable than their predecessors; indeed, that’s why new development is appealing to investors and how it is made possible.  Overall, that’s a good thing.  But small businesses either go under, unable to afford new rents, or relocate as a result. “ In housing policy, when an area is rezoned many cities now have inclusionary zoning policies e.g: “a percentage of units in a new development or a substantial rehabilitation that expands an existing building set aside affordable units in exchange for a bonus density. The goals of the program are to create mixed income neighborhoods; produce affordable housing for a diverse labor force; seek equitable growth of new residents; and increase homeownership opportunities for low and moderate income levels.” But that policy doesn’t necessarily translate to the rezoning of small, local businesses run by lower and middle class populations.

Furthermore, the potential negative implications of redesigning run-down suburbs don’t just apply to small business owners; development and the resulting risk of gentrification can hurt the workforce and overall economy of an entire region as is the case in DC where the free market is picking winners and losers by pricing much of DC’s workforce out of the area.

This can happen in cities and in suburbs. And—as my economics side must loudly add—that’s just capitalism functioning as it’s supposed to! Without a “check and balance” of some sort, that’s the way our system is meant to function.

Alas, the challenges remain—and professor Dunham-Jones spoke eloquently to these: How do we ensure beautifying old structures isn’t pushing out the very people who are making the only use of them? How do we even determine if in fact retrofitting efforts ARE having an impact on health? And finally, I’d push us to ask: are we getting at the roots of the problem? Increasingly more and more people across the country are spending less time using services, purchasing goods and/or enjoying public space.  America’s poor paying jobs that demand long hours, multiple shifts, and/or too much time in transit are squeezing our middle class. An extreme example, but one we could do well to learn a lesson from before it’s too late, is that of China’s ghost cities, captured here on CNN.

I see the benefits of retrofitting our suburban landscape, and through Professor Dunham-Jones’ lecture, have learned of the amazing structures and spaces erected, community built, economies revitalized and local business improved through such efforts. I recognize health is not the only goal in redeveloping our suburban landscape, and equity can’t be the sole factor in determining repurposing projects. But that’s the lens I wear. And for those most sick and in most in need of a louder voice, I can’t help but ask, “How do we decide fairly which space to retrofit?”

Conferences - Another Opportunity to Learn

Christina R. Hanna, MPH

 

Population Health Service Fellow

 

AIDS/HIV Program, Division of Public Health

 

Madison, Wisconsin

 

One of the many benefits of being a UW Population Health Service Fellow is the ability and support that we receive to attend various conferences throughout our two years as a Fellow.

In the first 16 months of the Fellowship, I have had the opportunity to attend seven conferences, each one teaching me something new about public health and about myself. As an early career public health professional, I have approached conference attendance with three main goals:

·       To network with other professionals, locally and nationally

·       To learn more about public health and find the topics, people, programs, public health models and tools that are most interesting to me

·       To learn more about others’ work and how I can make my mark on the public health landscape, i.e., trying to figure out what I want to do when I grow up

Other Fellows shared that they attend conferences to:

·       Receive training and learn from seasoned public health professionals who are doing work that we would like to do one day  

·       Learn about public health from different perspectives including local, state, national, business, non-profit, and academic

·       Learn new skills and tools to use in our work

·       Meet other professionals who share our same interests and passions

·       Get out of the office and immerse ourselves back into a learning environment

·       Network and meet people who are doing really interesting work and discover opportunities for future projects and collaboration.

·       Practice “elevator speeches” about the work we are doing

·       Have the opportunity to showcase the great work we are doing

Fellows also receive support to submit abstracts to conferences for poster and oral presentations. A number of Fellows have had abstracts approved and have presented oral and poster presentations at local and national conferences. Later this week, November 2-6, 2^nd year Fellow Carly Hood will be attending the American Public Health Association’s (APHA) AnnualConference in Boston and giving an oral presentation on her work titled: “Increasing capacity to promote health equity: Using evaluation toinform a professional development curriculum”.  

Fellows have attended a wide variety of conferences that help us learn more about public health, as well as other interests. Some of these conferences have included:

·       Wisconsin Public Health Association (WPHA)Annual Conference

 

·       American Public Health Association (APHA) Annual Meeting and Exposition

·       National Association of County and City Health Officials (NACCHO) Annual Conference

·       Wisconsin Prevention Conference

·       Wisconsin Health Education Network (WHEN) Annual Meeting

·       Minnesota Evaluation Studies Institute (MESI)Annual Conference

·       2012 Ryan White Grantee Meeting

 

·       Placemaking Conference

·       Community Engagement in Research (CEnR) Conference

·       YWCA Racial Justice Summit

Second Year Fellow, Tyler Weber, and Fellow Alum, Katarina Grande, meet across the world in Kampala, Uganda

Second year, Kristen Audet, reflects on 2012 APHA conference

Reflections on the American Public Health Association’s Annual Meeting

Last month I traveled to the American Public Health Association’s Annual Meeting. The convention was held in San Francisco, California, a city that lives and breathes public health; you walk down the street and see the mandated composting bins at every establishment and signs proclaiming that vendors are no longer able to bag your purchases in plastic, but would you like to use a re-usable bag? I learned about a myriad of health issues, from “street medicine,” which provides healthcare to our homeless population, to lasting impacts from oil spills on the Gulf Coast. I also tried to listen in on the national conversation surrounding immunizations.
 I attended a packed, standing-room-only panel presentation, “Vaccination Controversies in Historical Perspective.” Dr. Robert Johnston, Heidi Lawrence, and Dr. Elena Conis presented three thought-provoking papers discussing the way vaccination programs and “vaccination-skeptics” have been viewed throughout history. Lawrence drew the distinction between the various exigencies of vaccination campaigns in American history, for example, polio was a potent and palpable risk to the American public and it was thus easy for public health professionals to demonstrate the need for the vaccination. In contrast, the 1976 National Influenza Immunization program had a harder go of it because the disease was not as visible, indeed they did not have the visuals of polio-stricken children to use in their campaign. Lawrence described polio and the 1976 flu as different “rhetorical situations.” This idea of differing rhetorics came on the heels of Dr. Johnston’s paper urging current practitioners to be more respectful of “anti-vaccinationists,” arguing that indeed some scientists that were high respected in their time were in fact anti-vaccine and it may be beneficial to the current “pro-vaccine movement” to engage further with their assumed counterparts. Finally, Dr. Conis explored comparisons between the anti-vaccine movement and earlier environmental and feminist movements. In sum, all three speakers encouraged what seemed to be a room full of “pro-vaccinationists,” to consider a broader perspective when fighting for their cause.
At the end of the presentations and Dr. James Colgrave’s summing up perspective as discussant, a county health officer stood up and offered that while all this information was excellent in context of cultural competency and other ideations of theoretical complications surrounding the controversy, he was struggling to translate this into the actual, every day practice of raising immunization rates. I too, struggled with this question. One panelist later suggested we shift to calling the movement “vaccine-skeptics” instead of “anti-vaccine,” as many members of the movement are merely questioning the safety of vaccines, and not the overall efficacy of inoculation. The suggestion to reconsider what we call “the other side” gave me pause and I wondered how we may use these considerations in our practice in rural Wisconsin.
The Southern Wisconsin Immunization Consortium has always been open to anyone concerned about vaccinations in the region. Our mission and goals relate directly to raising immunization rates across the population, but we have always held an open door policy. If anyone wanted to join our meetings who were “skeptical” of vaccines, they would not be turned away. Yet- no skeptics have emerged. However, I have begun to think that we may need some. Listening to these panelists present made me consider how to best “fight” the “other side,” and the difference between silencing and “dialoging,” (a word which in this instance I will not shy away from saying for me is closer to “discrediting”). I would welcome some further pushback. I think that our initiative can only be strengthened from learning from the vaccine skeptics. Instead of completely shutting each other out, I encourage us to learn from each other. 

Second Year Fellow, Tyler Weber writes about public health and determinants of peace

Public Health and Determinants of Peace

Peace is not an imaginary distant utopia; it is a measureable, designable, and achievable human outcome. Thanks to the Institute for Economics and Peace (IEP), we now have an evidence-based platform to critically and meaningfully introduce the determinants of peace into our research and practice in public health.

Discussions of peace and public health, although sparse, have existed for some time. In 2002, Laaser and colleagues suggested that public health professionals could play a role in promoting peace by utilizing multiple approaches to mitigating violence.¹ Around the same time, others noted that health and peace can’t exist without each other,² and that “peace through health” should become a new discipline in health sciences.³ These editorials and commentaries highlighted important issues, however, a critical point was made--the growing interest and movement in peace through health needed evidence.⁴

Established in 2009, the IEP is a non-profit, independent, non-partisan research organization that creates conceptual frameworks and metrics for defining and measuring peace.⁵ It was formed after the Global Peace Index (GPI) found strong correlations between peacefulness and national wealth.⁵ Since then, the GPI has enabled IEP to create an evidence-based framework of the determinants of peace.

Structures of Peace is a notable publication by IEP that lays out a statistically grounded conceptual framework for peace.⁶ Figure 1 highlights eight key determinants associated with peace,⁶ some of which are also found in public health models:

Figure 1: Institute for Economics and Peace Conceptual Framework
http://economicsandpeace.org/wp-content/uploads/2011/09/Structures-of-Peace.pdf

Determinants in the IEP conceptual framework, such as high levels of education and good relations with neighbors, have also been found in the public health literature to benefit individual and population health.  In contrast, the role the business environment plays in health doesn’t often enter the public health discourse even though it is a prominent determinant of peace. It has already been suggested that achieving public health objectives may be paramount for successful peace building in a post conflict setting,⁷ but it would be limiting to think that peace can be defined only as the absence of conflict. Peace isn't merely the absence of violence or conflict, but rather it is a condition that exists in the presence of attitudes, institutions, and systems that foster peaceful communities and environments.⁶

Similarly, the World Health Organization specifies that health isn't merely the absence of disease, but as a state of complete physical, mental and social wellbeing.⁸ Consequently, we must continue working towards the elimination of violence, poverty, hunger, and disease, but we may only be successful when we simultaneously build structural peace.

This framework presents an opportunity for those of us in public health to explore the symbiotic relationship between peace building and public health efforts. We are in a position to collaboratively and collectively work across sectors and disciplines to build and sustain healthy and peaceful communities and environments.

In closing, I'll share a quote from IEP found in the Structures of Peace: Identifying What Leads to Peaceful Societies publication.

"Peace is statistically related to better business environments, higher per capita income, higher educational attainment and stronger social cohesion. Therefore, by establishing the appropriate environment to support peace many other benefits will flow. In this light peace can be seen as a proxy for creating the optimal environment for human potential to flourish.^"6

An important question remains—where do we go from here?

Thoughtful comments and questions are most welcome.

Tyler Weber, MPH

Wisconsin Population Health Service Fellow

Population Health Institute

University of Wisconsin - Madison

tylweber@gmail.com

References

1.      Laaser, U., Donev, D., Bjegoviæ, V., & Sarolli, Y. (2002). Public Health and Peace. Croatian Medical Journal, 43 (2), 107 - 113.

2.      Levy,  B. S. (2002). Health and Peace. Croatian Medical Journal, 43(2), 114 -116.

3.      Macqueen, G., Santa-Barbara, J., Neufeld, V., Yusuf, S., and Horton, R. (2001). Health and Peace: Time for a New Discipline. The Lancet, 357, 1460 - 1461.

4.      Vass, A. (2001). Public Health Through Peace. British Medical Journal, 323 (7320), 1020.

5.      Institute for Economics and Peace. (2012). Institute for Economics and Peace: Quantifying Economics and its Benefits. Retrieved from http://economicsandpeace.org/.

6.      Institute for Economics and Peace. (2011). Structures of Peace: Identifying What Leads to Peaceful Societies. Sydney, New York, & Washington, D.C: N. A.

7.      Tasi, T. (2009). Public Health and Peace Building in Nepal. The Lancet, 374, 515 - 516.

8.      Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.