Public Health: Moving Forward

Colleen Moran, MPH MS
Wisconsin Population Health Service Fellow
Wisconsin Division of Public Health
Madison, WI




Public Health is cool, right? Well, I suppose it depends upon whom you ask. This became a topic of discussion the other day - how do we "rebrand" public health? How do we communicate what it is and how cool it is? Most of the time when I tell people I work in public health, they ask me something regarding primary care, something clinical. I have to gently let them know that I'm not in, "that kind of health," that, "I work in prevention - I try to change the environments we live, work, learn and play in, and incorporate health into policies, to make the healthy choice the easy choice, so that fewer people have to visit the clinic," I'm usually met with a blank stare and the inevitable followup question: "so what is it exactly that you do?"


That question, a good one I might add, is what I dedicate my blog post to today. I'd like to answer that question of "what is it that I do" and in the process, try to explain just how amazingly cool public health really is. So in recognition of National Public Health Week, this blog post is dedicated to celebrating the great successes public health has accomplished so far, while also focusing on where the future lies for the world of public health. And hopefully along the way I'll answer that nagging question.

How Far We've Come . . .

First, let's take a moment to remember how far we've come. Back in the early days of public health, contaminated water was causing disease outbreaks such as cholera (remember Dr. Jon Snow and the Broad St. pump?), overcrowding was leading to transmission of infectious diseases, workplaces were unsafe, and family planning was unheard of. Just a few generations ago mothers and father worried about their children contracting polio, measles and mumps, and many did with devastating effects. 

We've come a very long way. Listed below are 10 of the greatest public health achievements of the 20th century. To many, the achievements listed below are so basic that they virtually go unnoticed. However, I think it's time to pause and recognize how far we've come, thanks to public health.

Ten Great Public Health Achievements in the 20th Century

1. Immunizations*
2. Motor-Vehicle Safety
3. Workplace Safety
4. Control of Infectious Diseases
5. Declines in Deaths from Heart Disease and Stroke
6. Safer and Healthier Foods
7. Healthier Mothers and Babies
8. Family Planning*
9. Fluoridation of Drinking Water*
10. Tobacco as a Health Hazard

While  most of us take these advances for granted, there a few of the achievements on the list that create controversy and I would feel remiss if I did not make note of that (the * above denote these controversial public health practices). However, I do not want to spend time refuting the arguments people make against these public health achievements. Rather, I would like to use this blog post to acknowledge the fact that we've largely moved from the focus of the 20th century on infectious diseases and injury prevention to a 21st century focus on chronic diseases and the environments, systems and policies that must be changed to create a healthier world. There is so much more to be done in public health. It's time to move forward. 

So What IS Public Health . . . ?

So what do we mean when we say "environmental, systems and policy level changes"? Well, think about your daily routine: 

• How do you get to work? 
• How do your kids get to school and are they safe and happy there?
• Where do you purchase your groceries? 
• Where do your kids play outside?  
  

http://healthsciences.curtin.edu.au/teaching/soph_whatis.cfm

If you said you drive to work, is this because there is no public transportation? The research demonstrates that if you use public transportation you get more exercise simply getting to and from the transit stop than if you drove yourself, thereby helping you reach your recommended levels of physical activity. Not to mention the environmental benefits of using public transit which lead to improved respiratory health outcomes from cleaner air. We must change your environment so that you can access public transit but this must be done at a systems and policy level. This is public health. 

https://www.safeschoolscoalition.org/
RG-posters.html

If you said, "I drive my kids to school because it's too far for them to walk," or, "I don't feel safe letting my kids take the bus," that is public health. If you said, "my child is bullied at school," or,"the lunch they are fed is not healthful" - that too is public health. Where we site our schools, if our kids can incorporate physical activity into their daily routine by walking to and from school, if you feel that the neighborhood is safe enough for your children to walk in - this is your environment and changes to the systems and policies that create this environment must be made. This is public health. 

https://www.flickr.com/photos/35586421@N03/
3331755112/in/pool-683857@N21

If you said, "I drive 30 minutes to the nearest full service grocery store to purchase my groceries," this is a public health issue. What about the folks that don't have access to a grocery store because they don't have a car, can't drive, and/or there is no public transportation? How do we feed ourselves healthy foods if we can't access them, can't afford them, or have to spend hours per week simply in transport to retrieve them? What type of zoning we create, where we site our grocery stores, and what types of foods we sell in them create our environment and at the systems and policy level, we must make changes. This is public health. 




http://www1.ochca.com/ochealthinfo.com/docs/newsletters/whatsup/2013/13-04.htm

If you said, "my kids don't play outside," why is this? Is there no park in your neighborhood? Are there no sidewalks for your children to walk, bike or play on? Is there a  park but you don't feel safe sending your children there? Do the cars drive too fast to allow you to feel safe letting your kids walk anywhere? This is your environment and we can make systems and policy level changes to make it healthier. We can change the zoning regulations to allow for urban agriculture in empty lots and front yards, we can create "road diets" to slow down traffic, we can increase the pedestrian and biking infrastructure, plant shade trees, and create community centers. This is public health. 

So Where Do We Go From Here?

The new face of public health focuses on these upstream social determinants of health. Where you live, work, learn and play are the biggest factors in your health and well being. An example of such public health work in action is an op ed recently posted by my friend and fellow Fellow, Carly Hood, on How to improve the health of Wisconsin families.


County Health Rankings Model
University of Wisconsin Population Health Institute
County Health Rankings and Roadmaps 2014. www.countyhealthrankings.org

"In short, when people don't have access to education, healthy food options, safe and active living environments or transportation to and from a decent-paying job, their health suffers."


In short, EVERYTHING is public health. As public health professionals today, we work to create healthier environments in which to live, work, learn and play tomorrow.

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?”

Neighborhoods and Health: A Quick Trip to Spain

 

Marion Ceraso, MHS, MA
WI Population Health Service Fellowship
Program Director

On a trip to Valencia, Spain, with recent Fellowship readings on my mind, I was on the lookout for things like mixed use development, strong public transit, and pedestrian and bike friendly neighborhoods.  I like this quote from the National Center for Healthy Housing report:

“…in neighborhoods that foster the conditions that promote good health, one often sees a cascading series of mutually reinforcing attributes that together create prime conditions for health: pedestrian friendly neighborhood design reduces car usage, supports transit ridership, and improves air quality…;

mixed-use development increases the likelihood of locating healthy food and retail within neighborhoods while also encouraging walking as a mode of transportation…”

With the caveat that this is neither an exhaustive, nor a critical view of the city, here are a few positive examples and some random reflections:

"Virgin Plaza" - a sort of living room for the city

1.    Multi-use development in the urban center, and even in many suburban communities is mostly the norm, with co-location of businesses, housing, parks, and other recreational public spaces. There are pretty nice parks in both high and low-income neighborhoods. The Spanish tradition of daily walking and socializing out-of-doors is supported (mutually reinforcing attributes?) by having so many destinations within walking distance, including restored historic buildings, places of worship, art venues, restaurants, shops and farmers’ markets.  Valencia’s central market is incredible - one of Europe’s oldest and biggest – here’s a fun video from the market of an orchestrated flash mob.

Bus stop palm

Street Art!

                                      

2. Food venues offer fresh fruit, vegetables, fish.  Even lots of the fast food is comparatively healthy.

Not gross. Delicious.  What is it?

3.   The city has varied, accessible and convenient transport options, including… high speed rail! 

The “ave”(bird) goes over 300 km/h (193 mph) 

Slowing down to enter the station 

 4.   Bike lanes and bike sharing are relatively recent and very popular additions.

5.    Restoration of historic buildings means the city is more beautiful to walk through.

Restored mansion

City Hall

6.   Like many coastal cities, Valencia used to “turn its back on the water.”  But now the waterfront and beach have been cleaned up, and a pedestrian walkway added.  The area is reachable by tram and bus and very popular with locals and tourists.

7.   Valencia’s climate allows for clothes to be dried outdoors.  Almost  no one uses a dryer, which seems like a great thing for the environment, but also for relationships between neighbors, since most people live in apartments with stacked clothes lines and you inevitably have to go fetch your clothes when they fall on your neighbor’s line.

8.   Commercial activity downtown and in the historic district is vibrant.  One of the things that makes the city so fun to walk around are the classic old stores that remind me of a much earlier time in the US, when small family-owned businesses were the norm.  It’s changing fast, but in Valencia you can still find sewing supply stores that sell buttons, ribbon and thread; glove shops, hat makers, taxidermists, fan shops and locksmiths.

I cheated, this one is Segovia 

Forge/locksmith